Medicare Advantage PPO

By: Agnus Smith
Published: Wednesday, July 25 2018
Last Updated: 4 years ago

When you are considering a Medicare Advantage plan for your health insurance, one of the decisions you need to make will be the type of plan you choose. One of the options you have is the Medicare Advantage PPO plan. Initially, considering a PPO plan may be a little confusing, however, an in-depth look at the benefits offered may clear things up a bit. So let's dive in, and see how a Medicare Advantage PPO can help you.

What Is Medicare Advantage PPO?

A Medicare PPO plan is only one type of Medicare Advantage plan offered to members. It is considered a Part C plan, and any coverage provided is through an outside, independent, private health insurance company. There are many different companies that provide Part C Medicare plans, and they offer a number of different plan setups, including the popular HMO and Medicare Advantage PPO plans.

What Medicare Advantage PPO Covers

Wait, Another type of health insurance plan to consider? Yes, it is a different type of health insurance plan, but it provides different benefits from the standard health insurance plan people are used to. Since most people are used to obtaining an HMO through their past employers, this type of plan could provide a lot of relief, and reduce the anxiety of using a private health insurance company. A Medicare Advantage PPO Benefits are different from those of an HMO, and include the following:

  • They will pay more for standard services.
  • They pay more for hospital visits.
  • They Pay for out-of-network doctors.
  • You do not need a referral to see a specialist.
  • You have a better choice of in-network doctors.
  • If you have prescription coverage, they cover more on your prescriptions and require fewer medical exceptions.
  • Lower deductibles are common with Medicare Advantage PPO plans.
  • Medicare Advantage PPO Benefits are usually more balanced.

These are just a few of the positives that are involved with choosing a PPO plan. For most plans, a Medicare Advantage PPO will cover a visit to almost any doctor, a stay in any hospital, and a number of out-of-network physicians. There are fewer limitations for members to work around, and most members are happy with this freedom.

Are Prescription Drugs Covered?

Most Medicare PPO plan options include prescription drug coverage. Before signing up with a PPO Medicare Advantage plan, ask if the plan includes Part D, which is prescription drug coverage. Some Medicare Advantage plans require you to sign up for Part D separately, so ask the company before you enroll whether you will automatically be covered or not.

How Medicare Advantage PPO Plans Work

To qualify for any Medicare Advantage plan, you must be eligible Medicare. During certain times of the year, you are allowed to move from one Medicare plan to another. These times are as follows:

  • Initial Enrollment Period - You can choose Original Medicare or a Medicare Advantage plan. You can also add prescription drug coverage as well.
  • General Enrollment Period - While you can’t enroll in a Medicare Advantage PPO plan, this is when you have a chance to enroll in Medicare Part B (January 1 through March 31). Part B is required before you can enroll in any Part C plan.
  • Open Enrollment Period (Annual Election Period) - Where you have a chosen to pick up, drop, or change health insurance plans or prescription drug coverage. This takes place from October 15 through December 7 each year.
  • Advantage Disenrollment Period - January 1 through February 14th. You can disenroll in any Part C plan you signed up for during Open Enrollment.

Most people who enroll in a Medicare PPO do so during Open Enrollment. If this is when you enrolled in a PPO, your coverage will begin on January 1.

Do You Need A Primary Care Physician?

Unlike most Medicare plans, there is no requirement to choose a primary care physician. There is also no requirement to choose a doctor that is considered in network. This relieves a lot of stress from people who are new to Medicare and do not want to change doctors to suit their plan requirements.

Even though you are not required to have a primary care physician, for the sake of keeping your medical records in one location, and receiving consistent, quality medical care from someone who is knowledgeable about your health situation.

Do You Need Referrals To See A Specialist

One of the Medicare Advantage PPO benefits is that in most cases, you do not need a referral to see a specialist. However, if you do choose an in-network specialist, you will see substantial cost savings from your visit.

Staying In Network

An added Medicare Advantage PPO benefit is that you do not have to stay in-network when you are choosing doctors. Your plan will cover a substantial amount of the cost associated with your visit, but there are limitations to your coverage. Your PPO plan will cover the same amount as they would for an in-network doctor, and you will have more out-of-pocket expenses than you would if you saw an in-network physician.

Since you do not have to stay in-network to see a provider, or to see a specialist, you will have more freedom, and be able to choose doctors that suit your needs a lot easier than you could if you were required to stay in network.

What Extra Benefits Are Included In Advantage PPO Plans

There are a number of extra benefits associated with a PPO plan. One of the most notable benefits is that you have more options when you are choosing a doctor or hospital. You also have the benefit of needing fewer prior authorizations and medical exceptions, which take valuable time away from you receiving the right medical treatment or medications.

If you sign up for a PPO plan during the Open Enrollment Period and you change your mind shortly after, you can remove yourself from the PPO plan during the Medicare Advantage Disenrollment Period, which is between January 1 through February 14th each year, right after Open Enrollment ends.