MEDICARE ADVANTAGE PPO PLANS

 

 

Preferred Provider Organization (PPO)




How PPO Plans Work


A Medicare PPO Plan is a type of Medicare Advantage Plan (Part C) offered by a private insurance company. PPO Plans have network doctors, other health care providers, and hospitals. You pay less if you use doctors, hospitals, and other health care providers that belong to the plan's network. You pay more if you use doctors, hospitals, and providers outside of the network.


Can you get your health care from any doctor, other health care provider, or hospital?


In most cases, you can get your health care from any doctor, other health care provider, or hospital in PPO Plans. Each plan gives you flexibility to go to doctors, specialists, or hospitals that aren't on the plan's list, but it will usually cost more.


Are prescription drugs covered?


In most cases, prescription drugs are covered in PPO Plans. Ask the plan. If you want Medicare drug coverage, you must join a PPO Plan that offers prescription drug coverage. Remember, if you join a PPO Plan that doesn't offer prescription drug coverage, you can't join a Medicare Prescription Drug Plan (Part D).


Do you need to choose a primary care doctor?


You don't need to choose a primary care doctor in PPO Plans.


Do you have to get a referral to see a specialist?


In most cases, you don't have to get a referral to see a specialist in PPO Plans. If you use plan specialists, your costs for covered services will usually be lower than if you use non-plan specialists.


What else do you need to know about this type of plan?


  • A PPO Plan isn't the same as Original Medicare or a Medicare Supplement Insurance (Medigap) policy.
  • PPO Plans usually offer extra benefits than Original Medicare, but you may have to pay extra for these benefits.


 

How do Medicare Advantage Plans work?


Medicare Advantage Plans, sometimes called "Part C" or "MA Plans," are an “all in one” alternative to Original Medicare. They are offered by private companies approved by Medicare.  If you join a Medicare Advantage Plan, you still have Medicare.  These "bundled" plans include  Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance), and usually Medicare prescription drug (Part D).



Covered services in Medicare Advantage Plans


Medicare Advantage Plans cover all Medicare services.  Some Medicare Advantage Plans also offer extra coverage, like vision, hearing and dental coverage.  Learn more about what Medicare Advantage Plans cover.


Rules for Medicare Advantage Plans


Medicare pays a fixed amount for your care each month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare.

Each Medicare Advantage Plan can charge different out-of-pocket costs. They can also have different rules for how you get services, like:


  • Whether you need a referral to see a specialist
  • If you have to go to doctors, facilities, or suppliers that belong to the plan for non-emergency or non-urgent care
  • These rules can change each year.


Costs for Medicare Advantage Plans


What you pay in a Medicare Advantage Plan depends on several factors. Learn about these factors and how to get cost details.


Drug coverage in Medicare Advantage Plans


Most Medicare Advantage Plans include prescription drug coverage (Part D). You can join a separate Medicare Prescription Drug Plan with certain types of plans that:

  • Can’t offer drug coverage (like Medicare Medical Savings Account plans)
  • Choose not to offer drug coverage (like some Private Fee-for-Service plans)


You’ll be disenrolled from your Medicare Advantage Plan and returned to Original Medicare if both of these apply:


You’re in a Medicare Advantage HMO or PPO.


  • You join a separate Medicare Prescription Drug Plan.


How Medicare Supplement Insurance (Medigap) policies work with Medicare Advantage Plans


Medigap policies can't work with Medicare Advantage Plans.

 Learn about your options related to Medigap policies and Medicare Advantage Plans.