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Considering Medicare PPO – Read This Before You Enroll

Medicare PPO plans have some attractive features but are they worth considering?Yellow Figures Linked by Network

If you are enrolled in Medicare you have some choices to make. You can stay with original Medicare and enroll in Part D, purchase a Medigap policy and enroll in Part D or join a Medicare Advantage plan that more than likely will include Part D coverage.

If you choose to enroll in a Medicare Advantage plan you may have Medicare PPO (Preferred Provider Organization) plans available.

This article is designed to give you an overview of what a Medicare PPO plan is, the pros and cons of PPO Medicare Advantage plans and give you a profile of who would benefit from this type of plan.

What is a Medicare PPO plan?

A Medicare PPO is a Medicare Advantage plan also known as Medicare Part C. Medicare Advantage plans are offered by private insurance companies approved by Medicare. The plan will provide all of your Part A and Part B coverage as well as emergency and urgent care coverage.

A Medicare Advantage PPO plan will include a list of doctors, specialists, hospitals and other providers. This list is your Preferred Provider Network.

You are allowed to receive services out-of-network but you will generally pay more. Cost sharing can take the form of co-payments, coinsurance or deductibles.

Most PPO Medicare plans include Part D drug coverage. Plans often include additional benefits not normally found in original Medicare like; dental, vision, hearing, gym memberships and other health and wellness programs.

 Medicare Advantage PPOs come in two varieties:

  • Regional Medicare PPO that may be single or multi-State
  • Local Medicare PPO that is offered in a single County

 Preferred Provider Organization (PPO) pros and cons

These pros and cons are relative to an individual’s needs and circumstances. What may be a major draw back for one person may be less so for another.

Pros

  • Medicare Advantage plans in general often have a lower premium than a Medigap policy and in some case offer a $0 premium.
  • A PPO network can give the best of both worlds: lower in-network cost and the freedom to go out-of-network.
  • Peace of mind knowing what your services will cost.
  • Saving money by choosing a plan with Part D coverage.
  • The extra benefits can be of value.

Cons

  • If the network is limited you may find yourself paying more out-of-network more frequently.
  • Overall costs for services are a little higher for a PPO than for a Medicare HMO plan.
  • If you choose a Medicare Advantage PPO plan without Part D coverage you cannot enroll in a stand-alone Part D plan.


Who will benefit by this type of plan?

If you weighed your options between a Medicare Advantage plan versus a Medigap policy and decided on the Advantage plan it’s now time to choose between the different types of Advantage plans.

Plans that include a Preferred Provider Network are popular choices because they offer a greater amount of flexibility than a Health Maintenance Organization (HMO).

Below are some characteristics of people who may choose a Medicare Advantage PPO plan:

  • Someone who likes the flexibility of a Medigap policy but cannot afford the premiums.
  • Someone who likes the idea of Medicare Advantage but doesn’t want to be locked- into a HMO.
  • Someone who wants an all inclusive plan that includes Part D as well as some extra benefits.

Your ability to enroll in a Medicare PPO  is subject to having plans available in your service area. Once you get the hang of navigating the medicare.gov website you should be able to locate all available plans.

 

If you are considering enrolling in a Medicare Advantage plan a PPO may be a good choice. Compare plans online or visit the Medicare website to find plans that may suit your needs.

 

2 comments

  1. Hi David,
    Thank you for the informative article on comparing original medicare with “medicare complete”. After reading all the information, I am still unclear about whether the PPO plan of Medicare Complete allows me identical flexibility in terms of choosing my own doctors and hospitals. I understand that out-of network facilities cost more, but would I really be entitled to use anyone, anywhere? Have you any additional information that might enlighten me? Also, I noticed the Medicare Complete plans have both local and regional networks. If I elected to travel beyond those areas for medical treatment, could I still select my own doctors and/or hospitals outside that area? And finally, have you done any research on whether more physicians and medical facilities accept one plan over the other? Thanks much for the invaluable service you are providing. Regards, Maria Young

  2. Maria Great questions!
    Q. Would I really be entitled to use anyone, anywhere?
    A. Here’s what it states in the 2011 AARP MedicareComplete enrollment kit: “You can go to doctors, specialists, or hospitals in or out of network. You may have to pay more for the services you receive outside the network, and you may have to follow special rules prior to getting services in / or out of network. For more information please call the customer service number.”
    Q. If I elected to travel beyond those areas for medical treatment, could I still select my own doctors and/or hospitals outside that area?
    A. That is my understanding. There is also a program called UnitedHealth Passport that allows you to use in-network providers in other States.
    Q. Have you done any research on whether more physicians and medical facilities accept one plan over the other?
    A. I have not as there are literally dozens of networks across the Country and the verbiage for both types of plans treat out-of-network usage the same.
    You can get more specific information at the website for AARP Medicare plans.

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