Medicare Advantage PPO Plans

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Medicare PPO plans can give beneficiaries more freedom than an HMO. Medicare Advantage plans are sold by private insurance companies; they may have different costs and features.

Some Medicare Advantage plans are PPO, or “preferred provider organization” plans, while others are HMOs, or “health maintenance organizations.”

PPOs give you more flexibility in managing your health care, but they usually cost more.

Medicare Advantage PPO Plans: Rules and Costs

Medicare PPO

A Medicare PPO policy may cost more, but it gives you more freedom

All Medicare Advantage plans must offer the same set of benefits as traditional Medicare Parts A and B. Therefore, a service or procedure Medicare covers must have coverage under the Medicare Advantage plan.

A central feature of a PPO plan is its network of doctors, hospitals, labs and other healthcare providers. If you visit a provider in the plan’s network, you pay copays, coinsurance or other costs at the “in network” rate.

You can see a provider outside the network if you want, but the visit is “out of network” and your out-of-pocket costs are higher.

PPO plans have a “maximum out of pocket” — the most you can spend out of your own pocket for healthcare during the year.

Once you reach the out of pocket maximum, the plan picks up all your costs for services with coverage. With a PPO plan, you typically don’t need a referral from your primary care doctor to see a specialist. Many Medicare Advantage PPOs include prescription drug coverage, and some even offer vision and dental benefits.

Because PPOs are sold by individual insurance companies, the costs, out of pocket maximums, and types of plans available will vary depending on the insurance company, the plan, and the area of service.

Eligibility for a Medicare Advantage PPO

To join any Medicare Advantage plan, you must enroll in Medicare Parts A and B. Then, the first time you can sign up for a Medicare Advantage is during the Initial Enrollment Period.

Your first enrollment period happens around the time you sign up for Medicare. After that, there’s an Annual Enrollment Period every year from October 15th-December 7th, and certain events may qualify you for a Special Enrollment Period.

Plans can change anytime, and most people notice more extreme plan changes when the new plan’s debut. Although, most people change coverage during AEP.

PPO is different than an HMO

Medicare Advantage PPOs and HMOs each have networks of healthcare providers. However, there are significant differences between the two.

With an HMO, you don’t have coverage if you see a doctor outside of the plan’s network. This means you may pay the full cost of care.

A PPO beneficiary can see non-network providers; however, it costs more than staying within the network. HMOs usually operate with a network of local healthcare providers. Some PPOs may have broader networks.

In general, a PPO plan is likely to have a higher monthly premium than an HMO plan. Although, a PPO plan provides you with more flexibility.

The difference between a Medicare PPO and Traditional Medicare

A Medicare Advantage plan must cover the same types of services as traditional Medicare Parts A and Part B.

Traditional Medicare is from the government; Medicare Advantage plans are sold by private insurance companies. This means that the premiums and out of pocket costs for Medicare Advantage PPO plans may vary.

Unlike Medicare Advantage plans, traditional Medicare doesn’t have provider networks. You can see whatever healthcare provider you want, so long as the provider accepts Medicare.

Traditional Medicare Part B pays a standard 80 percent of medical costs, but you can reduce your out-of-pocket expenses by buying a supplemental Medigap plan.

You can’t get a Medigap plan if you have an advantage plan.

Medicare PPO Coverage Could Be Right for You

Those looking for a portion of out of pocket coverage, with the lower price of an Advantage plan could benefit from a PPO. Advantage plans are great for beneficiaries under 65 on disability or for those with a limited income.

Some Special Needs Plans are available to beneficiaries with certain health issues.

Healthcare costs are rising, it’s important to find the right Medicare plan. MedicareFAQ can help by researching top insurance companies in your area and getting you free quotes on coverage.

Give us a call or fill out our form to start the comparison process. The best policy for you depends on your situation, call us to discover your best options.