Medicare PPO Plans
Approximately 11.5 million American beneficiaries are enrolled in Medicare Advantage (Part C) plans. Advantage plans allow beneficiaries to choose private insurance services that are approved by CMS. One of the most common types of Advantage plans is the Preferred Provider Organization (PPO) plan, which uses a managed care approached to keep costs low and are also limited to certain areas. If you enroll in a PPO plan, you are entitled to the same coverage you would receive from Part A and Part B of traditional Medicare.
If you are entitled to Part A hospital insurance and already have Part B medical insurance, you are eligible to enroll in an Advantage PPO plan. To qualify for a PPO, you must live within the PPO service region and must not be diagnosed with end stage renal disease (ESRD). You are eligible for PPO plans even if you have preexisting conditions (except ESRD). You can enroll for any PPO during the initial enrollment (when you first qualify for Medicare) or Annual Enrollment periods.
Most PPO plans offer coverage nationwide, with more extensive coverage available within the preferred provider network. Unlike an HMO plan, you do not need to select one primary care physician and can use any doctor within the PPO network. Usually, you are able to see specialists without a referral, although a referral may be necessary to receive expensive services like MRIs. Like HMO plans, PPO plans can offer additional services, like vision coverage, dental benefits, prescription medication coverage, and even gym memberships. You can still use doctors, hospitals, and specialists outside the preferred provider network, but this may come at an additional cost. Some PPOs will cover a percentage of the cost for health services outside the network.
Preferred Provider Organizations can cut down on your annual health care costs. If you use services within the network, you can save money on coinsurance, deductibles, and copayments. Depending on the plan you choose, you may need to pay premiums for prescription drug coverage and other supplementary benefits. Because most PPOs fill the gaps in Medicare Part A and Part B coverage, supplementary Medigap insurance may be unnecessary. Some PPO plans may have high out-of-pocket costs for certain types of specialty care. For the most part, you are only responsible for the copayment associated with your health services, but some PPOs include yearly deductibles that you must be aware of. Remember, you must continue paying your Part B premium if you wish to remain enrolled in any Advantage PPO plan.