PPOs and Medicare Advantage
Let’s take a quick look at Medicare Advantage as a whole before we dive into PPOs (Medicare Part C).
To supplement Original Medicare (Parts A and B), Medicare Advantage plans are available. Unless you enroll in a Medicare Advantage plan, your Original Medicare benefits will come directly from the government. We’ll go over Medicare Advantage PPO plans, one of the many Medicare Advantage plans available.
PPOs and other forms of Medicare Advantage may offer additional perks such as:
- Prescription drug coverage
- Routine dental care
- Routine vision care
- Routine hearing care
- Fitness club membership
- Nutrition counseling
…just a few of the advantages that may arise. However, these perks are not included in every Medicare Advantage plan.
Private insurance companies that are approved by Medicare offer Medicare Advantage plans.
What is a Medicare Advantage PPO plan?
One kind of Medicare Advantage plan is called a Preferred Provider Organization plan*, or simply Medicare PPO.
Both PPOs and HMOs (Health Maintenance Organizations) are widely used by Medicare recipients.
PPO plans typically have their own set of affiliated clinics and hospitals. Medicare Advantage PPO plans typically allow for use of non-network providers for Medicare-covered services; however, you may be responsible for paying a higher out-of-pocket maximum for your deductible and coinsurance if you go to an out-of-network provider. Make sure the provider is willing to see you and accepts Medicare before you have any treatment performed outside of the network. Out-of-network emergency care is covered by your Medicare Advantage plan.
PPO plans generally allow you to visit any doctor, specialist, or hospital that accepts the plan. You can see a doctor or specialist who isn’t on the plan’s network if you want to, but doing so will cost you more money.
Medicare Advantage PPO plans in more detail
A summary chart of Medicare PPO Advantage plans is provided below.
| Medicare Advantage Preferred Provider Organization (PPO) plan | |
|---|---|
| Are prescription drugs covered? | Usually, you should check with the plan administrator to be sure. Prescription drug coverage is only available through Medicare Advantage PPO plans. |
| Do I need to choose a primary care doctor? | No. |
| Do I need a doctor’s note to see a specialist? | You should check with your Medicare PPO plan to be sure, but in most cases, the answer is no. |
Medicare Advantage PPO plan costs
Costs associated with a Medicare Advantage PPO Plan membership include:
- The cost of having Medicare’s Part B coverage. This is something you’ll have to keep paying even if you switch to a Medicare Advantage plan for your healthcare.
- Regular payment is demanded by your Medicare Advantage plan each month. It’s important to remember that even if your Medicare Advantage plan doesn’t charge a premium, you still need to pay your Medicare Part B premium, even if your Medicare Advantage plan doesn’t charge premium.
- Medicare Advantage PPO plan-specific deductibles, coinsurance, and copayments.
Frequently asked questions
Are there Medicare PPO plans?
Medicare itself does not offer a PPO plan, but Medicare Advantage PPOs are available.
What other types of Medicare Advantage plans are there besides PPOs?
Medicare Advantage plans are not limited to preferred provider organizations (PPOs). Take, as an illustration:
- Most HMO plans require members to use a specific set of doctors and hospitals. In most cases, you can only use services offered by members of the network. In most cases, you’ll need to establish care with a primary physician. Most specialists will require a referral before seeing you.
- Plans that operate on a Private Fee-for-Service (PFFS) basis set their rates for services rendered. In most cases, you can visit any doctor who accepts Medicare assignment and is willing to treat you under the PFFS plan’s guidelines. Some PFFS plans have pre-established relationships with groups of doctors who have agreed to take the plan’s patients.
- Medicare recipients with specific health conditions qualify for Special Needs Plans.
When can I join, switch, or drop a plan?
Medicare Health Plans and Medicare Advantage Plans (Part C) with or without prescription drug coverage are available for enrollment, changes, and cancellations during the following times of the year:
- During the Initial Enrollment Period, you can sign up for a Medicare health insurance plan.
- From the 15th of October until the 7th of December each year is the Open Enrollment Period, during which time you can enroll in, change, or drop your plan. On January 1st, your coverage will go into effect (as long as the plan gets your request by December 7).
- If you are currently enrolled in a Medicare Advantage Plan and would like to change plans or return to Original Medicare (and enroll in a separate Medicare drug plan), you may do so once a year, during the Medicare Advantage Open Enrollment Period, which runs from January 1 through March 31. Please be aware that you will only be allowed one plan change during this time frame.
Are all Medicare Advantage PPO plans the same?
You can expect to find the regulations or features listed in the table above in most Medicare Advantage PPO plans. However, beyond Original Medicare (Parts A and B), some plans may provide additional benefits.
If you’re interested in a Medicare Advantage PPO plan, you must shop around. To get started, simply enter your zip code in the box provided.
No Preferred Provider Organization (PPO) plan member is obligated to receive care from an out-of-network or non-contracted provider except in an emergency. You or your provider can get a pre-service organization determination from us to find out if we will pay for an out-of-network service before you get it. For more information, including cost-sharing for out-of-network services, please call our customer service number or refer to your Evidence of Coverage.
