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Medicare PPO – Medicare Advantage Plan Option

Colorful Figures with Arms RaisedChoose Medicare PPO if you want a flexible Medicare Advantage plan

If you have been exploring your Medicare options you have probably noticed that there are different types of Medicare Advantage plans available.

If having the flexibility to choose your  providers is important to you consider a Medicare PPO plan. PPO plans give you the option to use providers within the network or for a higher out-of-pocket cost use providers that are out-of-network.

Other plans available include Medicare HMO plans Private fee-For-Service PFFS plans and HMO-POS plans.

Medicare PPO vs Medicare HMO

When comparing Medicare Advantage plans, you will most likely find that the majority of the plans available are either PPO plans or HMO plans. Both are network-based plans but do have some significant differences.

Medicare HMO – This is a network-based plan where you will choose or be assigned a primary care provider who will generally manage your care. You will be required to obtain a referral from your primary care provider in order to visit a specialist. You will also have to use hospitals and outpatient facilities that are in the HMO network.

In return for having a captive audience  health care providers will generally offer attractive terms to insurance companies that result in less out-of-pocket costs for members and often richer benefits. You may find that HMO plans have lower co-pays and may include more extra benefits beyond what original Medicare provides.

With this type of plan you will have to decide if the potential for lower costs and richer benefits can be reconciled with less flexibility to choose your own medical providers. Medicare HMO plans are most popular in areas that have a greater density of population.

Medicare PPO – This is a network-based plan where you will have access to a network of preferred providers who are offering a discounted rate for medical services. Most often you will have to identify a primary care provider when you enroll in a Medicare PPO Advantage plan but will not be required to visit that provider. With a Medicare PPO you will  not need a referral from your primary care provider to visit a specialist.

The biggest benefit of a PPO plan compared to a HMO plan is the ability to go out-of-network to receive medical care. Out-of-network care will generally require a higher co-pay or coinsurance amount with the exception being emergency care.

Medicare PPO plans also include additional benefits beyond what is available from original Medicare. If you have both PPO plans and HMO plans available the network restrictions will generally be the factor that may sway you one way or another.

 Read This Before You Enroll in a Medicare PPO

Medicare PFFS and HMO-POS plans

PFFS plans are plans that are designed to allow you access to any provider that accepts Medicare assignment and accepts the plan’s payment terms and conditions. The downside of this type of plan  is that providers can accept the plan on a visit-by-visit basis. Often times these plans have higher premiums and offer less of the extra benefits that you will find in a PPO Medicare plan. Many Medicare Advantage plans that have not renewed are PFFS plans.

HMO-POS Medicare plans are almost a hybrid of a HMO plan and a PPO plan. Though not as common as a Medicare PPO plan they do afford some flexibility not found with a Medicare HMO plan. If you have a HMO-POS plan available it is worth considering.

There are many good HMO plans available if you can live with the network restrictions but if you want more flexibility choose a Medicare PPO.  It’s difficult to put a dollar figure on the the freedom to go out-of-network if the need arises.



  2. Gail, 2011 Medicare Advantage plans are offered on a County-by-County basis and there are literally hundreds of plans. Plan design and rates can vary by County. To find rates on 2011 Medicare PPO plans, visit the official Medicare website, as they have infinitely more resources than me, an individual blogger. For Medigap plans, search for a Department of insurance site in your State. Medigap rates are public knowledge and must be published. I’m sorry you didn’t provide me more information, because I could have provided a link. I hope I have answered your question to your satisfaction.

  3. Shirley R Hemphill

    i presently have healthspring in chattanooga tn,at present I have vision and dental that will not be offered on my present plan in 2011.I want the plan that does offer the vision and dental,which one is it. Thanks

  4. Shirley, visit the HealthSpring website and enter your zip code. You can compare up to 3 plans. It looks the HealthyAdvantage Primary may afford you the best dental and vision benefit. You have 15 2011 Medicare Advantage plans available in Chattanooga TN Hamilton County. You may want to look at some other companies as well to see if any offer more comprehensive benefits.

  5. I am shopping medicare coverage for my 90 year old dad. He needs dental and vision as well. He lives on a fixed income, very fixed. His overall health is fair. He does need to be able to take physical therapy periodically, due to a weak lower back. He presently has Aetna and it has been fair. He keeps hearing about Texas HealthSprings. He lives in 77386 area code. Thank you for your assistance, I find this all VERY CONFUSING!

  6. Jill, There are three 2011 HealthSpring Healthy Advantage Medicare plans in the zip code 77386. Visit the HealthSpring website and enter your Dad’s zip code on the home page to view and compare plans. Scroll down to see links to the plan’s Summary of Benefits. The Summary of Benefits will give you more detail so you can make an informed decision.

  7. Michael Santaniello

    Retired June 30 ’09, from teaching. I chose least expensive med advantage plan
    sponsored by the Manatee County School District which was offered by UHC
    Secure Horizons. The monthly premium Oct 1 ’09 was $212 and increased to
    $252 on Jan 1 ’10. I find my co-pays for doctors visits are quite small, however
    I don’t anticipate hospital or out-patient services in 2011. My prescription drug
    plan at Sweetbay pharmacies are covered in their formulary, most at $4.00 per
    30 day refill. My question is: my premium costs annualy seem to be very high
    for the benefits I receive…maybe not? And the plan doesn’t cover dental, vision,
    etc. Thanks, Michael

  8. Michael, Are you certain that you have a Medicare Advantage plan? If you live in Manatee County there are two Secure Horizon plans available; AARP MedicareComplete Choice Plan 2 (regional PPO) and AARP MedicareComplete Plus Plan 1 (HMO_POS), both plans have a $0 monthly premium. Maybe you have a Medicare Supplement on a list bill through your former employer? Your premiums don’t sound like Advantage plan premiums.

  9. David, My retireed sister also has a UHC Medicare Advantage plan sponsered by Manatee County School District. It is a Group plan and she pays a monthly premium of $266 for 2011 with a $250 deductable. Another strange thing is, last year it was a UHC Secure Horizons plan and this year they dropped the Secure Horizons name. I have a UHC Secure Horizons Medicare Advantage plan with a $0 montly premium, slightly higher co-pays but very similar. My sister is very upset and feels as if she is being taken advantage of. We are fixing to change her coverage. Please comment, Jim

  10. Jim, Sounds like a frustrating situation for your sister. So often people who have been with an employer for many years assume that the health plan offered after retirement must be by default the best option. The assumption is that it is a a true benefit much like a pension. I often have input from retirees who are in a group health insurance plan but would actually have lower premiums and less out-of-pocket with a Medigap policy.

    I am not an expert on group Medicare Advantage plans so here is a fact sheet on United Health Care Group Medicare Advantage plans. Beginning in 2011 the Open Enrollment Period (Jan 1 – Mar 31) is no longer available. Switching Advantage plans is not an option after January 1 without some type of Special Enrollment Period. The is now an Annual Dis-enrollment Period (Jan 1 – Feb 14) where someone enrolled in an Advantage plan can drop that plan and return to original Medicare. They can then purchase a stand alone Part D plan and a Medigap policy if they wish. Medicare Supplement Plan N is fast becoming a popular option to an Advantage plan.

  11. Dave, I have medicare Complete plan from United Health Care.It is a PPO. When I go to the Dr. I no longer use my original Medicare Card. I am told my current plan takes its place. My next door neighbor has the same insurance. She is told to still use her original medicare card as primary insurance. I can’t find any difference in the 2 plans. What is the deal.? My zip code is 46545

  12. Howard, Your experience is what is supposed to happen. If your neighbor has the same plan and she is only showing her original Medicare card, the provider is not getting paid. Highly unlikely! The office staff is probably confused when your neighbor has a doctor visit and is asking erroneously for the original Medicare card and may have a copy of her Medicare Complete card on file. It’s also possible that they are a highly inefficient office and haven’t realized that they are not getting funded yet.

  13. My wife and I have BC/BS Health options HMO, this is for Broward County only. We live in Ft. Lauderdale but intend to move to Kissimmee, Florida which is in Central Florida. The plan I have is not offered in central Florida. I’m told that I can only change my plan in December of each year, what do I do in this case?

  14. Ron, I believe that you will have a Special Election Period and will be able to join a plan prior to December. Call SHINE (Serving Health Insurance Needs of Elders) at 1-800-963-5337 to verify.

  15. Whats the difference between antna healthcare ppo 2012 and anthem healthkeepers hmo 2012?

  16. Robert, If you are trying to compare benefits between the two plans you mentioned you will need to get your hands on each plan’s Summary of Benefits. Benefits for Medicare Advantage plans can be different from one service area to another. Visit each plan’s website to do a comparison.

  17. I am new to medicare. been on social security disability for 2 yrs. I can’t get a supplement cause I am not 65. got a blue cross anthem plan to help with drug costs. then I find out it takes the place of my medicare . medicare does not pay on anything. So why am I paying 106 a month for medicare and 70 to blue cross? I should not have to pay 106 for nothing

  18. Jan, You are enrolled in a Medicare Advantage Plan which typically has certain benefits not usually found in original Medicare. You should spend some time with the Medicare & You Handbook available from Medicare or sign up for my Free 8 part Video Mini-Course so you can get a better grasp on what you’ve signed up for. It may or may not be the best thing for you. Also if you find the extra benefits included in an Advantage plan to be helpful, you may find that other companies offer the same type of plan without a monthly premium. Plans are offered County by County and you may or may not have a $0 premium plan available. The first step is to educate yourself on your options. And by the way… if you did qualify (or when you do at age 65) for a supplement you would still pay the Medicare Part B premium and the premium for the supplemental coverage.

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