PPO
Medicare Advantage PPO Plans
Preferred Provider Organization (PPO) plans give their members more freedom than Health Maintenance Organization (HMO) plans provide. In Medicare, PPO plans Medicare Advantage plans that are sold by private insurance companies who have been approved by the federal program to offer such plans. Since these are not standardized, each carrier can dictate the coverage and costs for each plan. Medicare Advantage PPO plans have some great features, but the premiums are higher than HMO plans.
Medicare Advantage PPO Plan Benefits
The most notable feature of any PPO plan is its network of providers and facilities. If a plan member stays within the network, they’ll enjoy the maximum amount of benefits that the plan offers. There are copays and coinsurance expenses associated with these plans.
PPO plan members are not limited to the network. They can receive care from providers and facilities who are outside of the network, but the coverage will be less and the member’s out-of-pocket expenses will be higher than if they had stayed in-network.
Many of the Medicare Advantage plans have a maximum out-of-pocket limit. As it sounds, this number is the most any person on that plan will pay out-of-pocket. Once they have reached that limit, the plan pays for 100% of the costs for the remainder of the plan’s benefit period.
PPOs do not require their members to designate a primary care physician, nor do they require a referral to see a specialist. Unlike a Health Maintenance Organization (HMO) plan, a Preferred Provider Organization plan allows you to have the freedom to receive care from any health care provider that is active within or outside of your network. Nevertheless, it is always advisable to stay within your plan’s network to avoid additional costs unless you don’t mind paying a larger potential out-of-pocket amount.
Many of the Medicare Advantage PPO plans include prescription drug coverage and even offer additional benefits for dental, vision, and hearing services.
Medicare Advantage PPO Eligibility and Enrollment
Any Medicare beneficiary who has already enrolled in Medicare Parts A and B is also eligible for the Medicare Advantage PPO plan, with one exception. Individuals who have already been diagnosed with End-Stage Renal Disease (ESRD) are not eligible for any Medicare Advantage plan. Otherwise, an individual can enroll in a Medicare Advantage plan during their Initial Enrollment Period or during the Annual Enrollment Period. Some individuals that face certain special situations such as losing health coverage, moving, getting married, or having a baby may even qualify for a Special Enrollment Period.
Medicare Advantage PPO plans are not available in all areas. Work with a licensed agent to find out which plans are available in your area.
Comparing PPO Plans to HMO Plans
The PPO and HMO plans in Medicare Advantage work very similarly. They each have their own network of providers and work best when their members see those providers. However, there are some benefits that PPO plans have over HMOs.
Even though PPO plans have a network, their members can go outside the network and still have benefits available. That being said, the member will have higher out-of-pocket expenses when this happens. HMO plans generally offer no benefits outside of their network, leaving a member who goes outside the network to pay their full cost for services. PPOs generally have a wider network than HMOs.
The extra benefits of a PPO plan cause these plans to come with a higher premium than the HMO plans.
At the end of the day, it comes down to what you individually find most important and valuable while looking for adequate health insurance. Make sure you take a detailed look at both plans before making a decision and consider PPO plans especially if flexibility is what you are looking for.
Comparing Medicare PPO Plans to Original Medicare
Medicare Advantage plans are alternatives to Original Medicare. They offer the same benefits (at a minimum), but have major differences.
Original Medicare does not require beneficiaries to stay in a specific network. Individuals can choose to see any provider. If the provider accepts Medicare assignment (which most do), Original Medicare will cover the maximum benefits. If the individual chooses to see a provider who does not accept Medicare assignment, the individual may have to pay excess charges. As we’ve mentioned, PPO plans do not offer as much coverage outside of the plan’s network.
Medicare Advantage plan members cannot purchase a Medigap (Medicare supplement) plan. They are only available to those enrolled in Original Medicare.
Most of the time, Medicare Advantage PPO plans will have lower monthly premiums than those associated with Original Medicare.
Original Medicare does not include prescription drug coverage. Individuals will need to purchase a stand-alone Part D plan. On the other hand, most Medicare Advantage PPO plans include prescription drug coverage.