A Medicare Advantage PPO plan is a type of Medicare Advantage plan offered by a private health insurance company.
Preferred Provider Organization (PPO) plans usually have an in-network or group of healthcare providers and hospitals from which to choose.
Choosing a health care provider that is in-network may cost less than choosing an out-of-network provider.
Read on to learn more about Medicare Advantage PPO health plans.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare Advantage plans are often referred to as Medicare Part C. They are provided by Medicare-approved, private health companies.
A PPO plan is comprised of a group, called a network, of healthcare providers and hospitals from which a person can choose. These providers will be cheaper than using providers outside of the network.
Most PPO plans are flexible, and a person can receive services from any healthcare provider or hospital. Choosing a provider that is out-of-network usually costs more, however.
A Medicare Advantage plan is a bundled plan that includes:
- Part A, hospital insurance
- Part B, medical insurance
- Part D, which covers prescription medication
Medicare Advantage PPO plans must cover the same services that original Medicare (Part A and Part B) covers. Some plans offer additional coverage including:
- wellness programs
Regardless of the plan a person chooses, emergency and urgent care is covered.
Medicare Advantage covers more services than they have previously, including:
- transportation to the doctor
- over-the-counter medications
- adult day care services
- wellness programs
The plan that a person selects can opt to deny coverage for health services that are not deemed medically necessary by Medicare.
If a person is unsure if their plan covers a particular service, it is best to call the provider before receiving the treatment.
People with a PPO plan usually have prescription medication coverage.
However, it is important to note that every PPO plan is different and may offer different coverage.
Many prescription drugs have a copay. The copay amount will usually be less for a generic drug than for a particular brand. It could be a percentage of the total or a set dollar amount.
The medication may also need prior authorization from the provider before they pay for it.
While PPO plans and Health Maintenance Organization (HMO) plans share many characteristics, PPO plans offer more flexibility.
A Medicare Advantage HMO plan member usually must receive their healthcare from a list of providers in the plan’s network.
In contrast, people with a PPO plan can choose someone from outside of their network, though it may cost more.
With HMO plans, some exceptions are made for:
- emergency care
- out-of-area urgent care
- out-of-area dialysis
While people with HMO plans usually need to choose a primary care physician from the plan’s list of providers, people with a PPO plan do not.
Medicare Advantage plans must adhere to certain rules set forth by Medicare.
However, each plan can charge variable out-of-pocket costs. They can also have different rules about how each plan member receives services, such as:
- whether a person needs to get a referral to see a specialist
- whether a person needs to a physician, facility, or supplier who belongs to the plan’s network for routine or non-urgent care
People should be aware that these rules can change yearly, so it is best to keep informed of the changes and always call the provider before receiving treatment.
The monthly cost of a PPO plan may depend on the services provided and other factors.
A person usually pays a monthly premium in addition to their Part B premium for Medicare Advantage coverage.
In 2021, the regular cost of a Medicare Part B is $148.50 per month. It may be higher depending on a person’s income.
Keep in mind that PPO plans often make changes on the 1st day of each year.
They may make changes to any or all of the following:
- pharmacy network
- provider network
- copayments and coinsurance
Each plan member should remember to read their annual “notice of change” letter, which is mailed each September.
Medicare Advantage PPO plans, also known as Preferred Provider Organization plans, have a network of providers such as doctors that costs less than other out-of-network providers.
PPO plans offer more flexibility than HMO plans, where a person can only go to healthcare professionals within their network.
Anyone concerned about whether their Medicare Advantage PPO plan covers a particular treatment or service should contact their provider.