Medicare Advantage plans utilize one of two types of networks. These groups of providers are either a PPO (Preferred Provider Organization) or an HMO (Health Maintenance Organization) network.

Access to more providers is the key reason people select a Medicare Advantage plan that uses a PPO network.

Insurance companies use cost-saving features such as a network of providers to stretch the purchasing power of each dollar. Medicare beneficiaries want access to more providers; that’s why more people are electing to enroll in a Medicare Advantage plan that uses a PPO.

With a PPO plan, the Medicare beneficiary can receive services in or out of network. The insurance pays more when you stay in-network but does offer some benefits if treatment is rendered outside the preferred network of doctors.

Medicare Advantage PPO plans must provide at least the same compensation package as Original Medicare. All Advantage plans must offer the same rights, benefits, and protections as Original Medicare.

Advantage plans are competitive because they offer additional benefits such as vision, hearing, and dental services.

How Medicare Advantage PPO Plans Work

Who is Eligible for Medicare Advantage PPOs?

You are eligible for a Medicare Advantage PPO if you live in the service area and have Medicare Parts A and B.

Medicare beneficiaries are eligible to enroll in a Medicare Advantage PPO during the following periods:

What is the difference between a PPO and an HMO?

A PPO (Preferred Provider Organization) utilizes a network of providers and pays a higher benefit when services are performed in the network.

Referrals are not required, and Medicare Advantage PPO plans tend to cost more than Medicare Advantage HMO plans because they pay a percentage of the benefit even out of network.

An HMO uses a tighter network of providers. In addition, the PCP (Primary Care Provider) acts as the gatekeeper, and the plan requires any services outside an emergency must first be addressed with the PCP. Services received without a referral may not be covered.

Are Medicare Advantage PPOs Different than Original Medicare?

A Medicare Advantage PPO is a different option from Original Medicare.

Original Medicare can be used at any doctor or hospital that accepts Medicare. After meeting your deductible, Original Medicare pays at 80% coinsurance for Part B services, leaving the Medicare beneficiary with an out-of-pocket responsibility of 20%.

You can select to purchase a Medigap policy to pay the 20% not covered by Medicare, or you can look at the Medicare Advantage plan options.

With a Medicare Advantage PPO plan, most services have only a small copay or coinsurance assigned to the beneficiary, provided you use the PPO network.

For example, a routine sickness visit at a doctor can cost upwards of $200 as a cash patient. With Original Medicare, the Medicare beneficiary will be responsible for the annual deductible plus 20% coinsurance.

With a Medicare Advantage PPO plan, the Medicare beneficiary would incur a copayment for a primary doctor visit. Doctor visit copays typically range from $20-$50. And most Medicare Advantage PPO plans don’t have a deductible.

What are the Benefits of a PPO?

The most significant benefit of a Medicare Advantage PPO plan is the small copays assigned to most services. Another factor in selecting an Advantage plan that uses a PPO network is the larger group of providers.

PPO plans don’t require referrals. When you need to see a specialist, you can contact one from your network without a trip to your primary doctor.

Further, a Medicare PPO plan pays reduced benefits if you decide to see a provider out of network.

PPO Common Characteristics

  • Low monthly premiums – PPO plans typically have premiums lower than Medigap policies.
  • In-network benefits – PPO plans will pay a higher benefit inside the plan network and a lower benefit
  • percentage out of the network, except in an emergency.
  • No health questions – To enroll in a Medicare PPO plan.
  • No Referral required – No referrals needed.
  • Part D drug coverage – Usually included in Medicare PPO plans.
  • Copays and coinsurance – Usually, insured persons pay a small copay for covered services in place of the 20% typically assigned by Original Medicare.
  • Annual plan changes – Most benefit changes are made and released by the insurance company before the annual enrollment period.

How to Get Help Enrolling in a Medicare Advantage PPO Plan

To say the world of Medicare Advantage is complicated is an understatement. Since every plan varies from carrier to carrier, it can be difficult to separate what’s important vs. what’s extra fluff. That’s where we step in.

Our licensed agents know the ins and outs and stay up to speed with industry changes to keep you, the beneficiary, informed. Give us a call, or complete our online quote form now.

by Lindsay Malzone, Lindsay Malzone is the Medicare expert for Medigap.com. She's been contributing to many well-known publications as an industry expert since 2017. Her passion is educating Medicare beneficiaries on all their supplemental Medicare options so they can make an informed decision on their healthcare coverage.
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