How Medicare Advantage PPO Plans Work

About Medicare PPO Plans

MEDICARE PREFERRED PROVIDER ORGANIZATIONS

HOW MEDICARE ADVANTAGE PPO PLANS WORK?

A Medicare PPO Plan is a type of Medicare Advantage Plan (Medicare Part C) offered by a private insurance company. PPO Plans have network doctors, other health care providers, and hospitals. You pay less if you use doctors, hospitals, and other health care providers that belong to the plan's network. You pay more if you use doctors, hospitals, and providers outside of the network.

 

WHAT ARE THE LIMITATIONS WHEN IT COMES TO DOCTORS WITH A PPO PLAN?

HOW MEDICARE ADVANTAGE PPO PLANS WORK WITH DOCTORS

In most cases, you can get your health care from any doctor, other health care provider, or hospital in PPO Plans. Each plan gives you the flexibility to see doctors, specialists, or hospitals that aren't on the plan's list, but it will usually cost more.

 

DO ALL MEDICARE PPO PLANS COVER PRESCRIPTION MEDICATIONS

No, not all PPO plans include prescription drug coverage. Many do, but you will need to confirm, as plans are specific to certain areas. In most cases, prescription drugs are covered in PPO Plans. Ask the plan. If you want Medicare drug coverage, you must join a PPO Plan that offers prescription drug coverage. Remember, if you join a PPO Plan that doesn't offer prescription drug coverage, you can't enter a Medicare Prescription Drug Plan (Medicare Part D).

DO YOU NEED TO CHOOSE A PCP WITH A PPO PLAN?

You don't need to choose a primary care doctor in PPO Plans. Many plans still recommend identifying a Primary Care Provider, but enrollment in the plan is not required.

 

WILL YOU NEED REFERRALS TO SEE A SPECIALIST WITH A PPO PLAN?

In most cases, you don't have to get a referral to see a specialist in PPO Plans. If you use plan specialists, your costs for covered services will usually be lower than if you use non-plan specialists.

 

OTHER IMPORTANT INFORMATION ABOUT PPO PLANS

• A PPO Plan isn't the same as Original Medicare (Medicare Part A and Part B) or a Medicare Supplement Insurance (Medigap) policy.

• PPO Plans usually offer more benefits than Original Medicare, but you may have to pay extra for these benefits.

  
  

 

HOW DO MEDICARE ADVANTAGE PPO PLANS WORK?

Medicare Advantage Plans, sometimes called "Part C" or "MA Plans," are an “all-in-one” alternative to Original Medicare. Private companies approved by Medicare offer them.  If you join a Medicare Advantage Plan, you still have Medicare.  These "bundled" plans include Medicare Part A (Hospital Insurance), Medicare Part B (Medical Insurance), and, in most cases, a Medicare Prescription Drug Plan (Part D).

WHAT IS COVERED UNDER MEDICARE PPO PLANS?

All Medicare Advantage Plans must offer the same coverage as Original Medicare. And the majority of MA and MA/PD plans include Dental Benefits, Routine Vision Care, Hearing, Hearing Aids, and a Health Club Membership through companies like SilverSneakers, Silver&Fit, and Renew Active.

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ARE THERE ANY RULES WITH MEDICARE ADVANTAGE PPO PLANS?

Medicare pays a fixed monthly amount to the companies that offer Medicare Advantage Plans for your care. These companies must comply with Medicare rules. Each Medicare Advantage Plan can charge different out-of-pocket costs. They can also have different rules for how you get services, like:

• Whether you need a referral to see a specialist

• If you have to go to doctors, facilities, or suppliers that belong to the plan for non-emergency or non-urgent care

• These rules can change each year.

  
  

HOW MUCH DO MEDICARE ADVANTAGE PPO PLANS TYPICALLY COST?

What you pay in a Medicare Advantage Plan depends on several factors. Where you live is the most significant factor. Some PPO plans have a $0 Premium, but they typically have higher MOOP amounts. Overall, PPO Plans can cost $25 - $175 per month, depending on the plans available in the county you live in.

 

DO MEDICARE ADVANTAGE PPO PLANS ALL COME WITH PRESCRIPTION DRUG COVERAGE?

Most Medicare Advantage Plans include Prescription Drug Coverage Medicare Part D). You can join a separate Medicare Prescription Drug Plan with certain types of plans that:

• Can’t offer drug coverage (like Medicare Medical Savings Account plans)

• Choose not to offer drug coverage (as some Private Fee-for-Service plans do). You’ll be disenrolled from your Medicare Advantage Plan and returned to Original Medicare if both of these apply:

• You’re in a Medicare Advantage HMO or PPO.

• You join a separate Medicare Prescription Drug Plan.

  
  

WHICH INSURANCE COMPANY HAS THE BEST PPO PLANS?

In my experience, Aetna has the best PPO Networks and plan options.

MEDICARE PPO PLANS ARE NOT ACCEPTED BY EVERY HOSPITAL

Did Anyone Mention To You That The Mayo Clinic Hospital & Barrow Neurological Hospital Do Not Accept ANY Medicare Advantage Plans? This is because Medicare Advantage Plans have strict Networks you need to use. If you go out of the Network, you will pay for services out of your own pocket.

 

It is true.  Many specialty hospitals, such as Cancer Treatment Centers of America, partner with only a few select Medicare Advantage Plans. This is why you need to read the fine print: unfortunately, most Medicare Agents are too focused on making the sale and intentionally side-step the truth.  If you do not ask, they do not volunteer information that will make them or their plan look bad. 

 

In all fairness, Mayo Clinic in Rochester, Minnesota, accepts all Medicare Advantage plans in Minnesota, but that is not the case in Arizona or Florida.