The term Medicare PPO stands for Preferred Provider Organization. It means that the Medicare insurance company has a network health providers that have agreed to see the plan’s members at contract negotiated rates. These network providers will coordinate your care.
Medicare PPOs are private health insurance plans through which you can get your Part A and B and sometimes D benefits, instead of through Medicare itself.
A Medicare PPO is a type of Medicare Advantage plan that you can join as a private alternative to original Medicare. In a Medicare PPO, you will generally pay lower co-pays if you see providers that are in the network. You are not usually required to choose a primary care physician or get referrals to see specialists. Each plan has its own rules though, so always check the plan’s summary of benefits before enrolling.
A Medicare Advantage PPO must provide your A & B benefits to you under the plan. The plan must include an out-of-pocket maximum cap on your spending. This cap protects you against catastrophic spending during a year when you are experiencing higher than normal medical costs.
In 2017, the maximum that any Medicare Advantage plan can set as your out of pocket max is $6700 per calendar year. That means that $6700 out-of-pocket on hospital and outpatient expenses is the worst case scenario.
When you enroll into a Medicare PPO plan, you may have the following kinds of expenses:
People new to Medicare often ask which is better: Medicare supplements or Medicare Advantage plans like PPOs? The answer is that it depends on your personal preferences. Medicare supplements (also called Medigap plans) pay after Medicare and leave you with very little out of pocket. Most of the time you will not even have a doctor copay. However, they are typically more expensive than Medicare PPO plans.
Medicare PPO plans will generally have lower premiums, but you agree to use a network of doctors to get the best copays. You will pay as you go along, so there will be copays collected from you at the time of each service. This includes doctor visits, lab-work, hospital stays, surgeries, durable medical equipment, diagnostic imaging, etc. Some people don’t mind this because they prefer a lower monthly premium. It’s completely up to you.
Yes, you must be enrolled in both Medicare Parts A and B and live in the plan service area to be eligible for a Medicare Advantage PPO plan.
Medicare PPO plans are just one option you have for your Medicare-related insurance coverage. They are not the same as Medigap plans. The coverage is different so you’ll want to understand both types of plans before you make your choice.
Selecting a plan can be tricky. You want to ensure that you will have access to the healthcare providers and medications that you require. A licensed agency specializing in Medicare plans can do this research for you at no cost. After you enroll through us, we provide support to you when you have questions about how your benefits will pay for certain services or claims.