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Medicare Advantage PPO Plans


Medicare PPO plans can give beneficiaries more freedom than an HMO. Medicare Advantage plans are sold by private insurance companies; they may have different costs and features. Some Medicare Advantage plans are PPO, or “preferred provider organization” plans, while others are HMOs, or “health maintenance organizations.” PPOs give you more flexibility in managing your health care, but they usually cost more.

What is a Medicare Advantage PPO Plan?

A central feature of a PPO plan is its network of doctors, hospitals, labs, and other healthcare providers. If you visit a provider in the plan’s network, you pay copays, coinsurance, or other costs at the “in-network” rate. You can see a provider outside the network if you want, but the visit is “out of network” and your out-of-pocket costs are higher.

PPO plans have a “maximum out of pocket” — the most you can spend out of your own pocket for healthcare during the year.

Once you reach the out-of-pocket maximum, the plan picks up all your costs for services with coverage. With a PPO plan, you typically don’t need a referral from your primary care doctor to see a specialist. Many Medicare Advantage PPOs include prescription drug coverage, and some even offer vision and dental benefits.

Because PPOs are sold by individual insurance companies, the costs, out of pocket maximums, and types of plans available will vary depending on the insurance company, the plan, and the area of service.

Eligibility for a Medicare Advantage PPO

To join any Medicare Advantage plan, you must enroll in Medicare Parts A and B. Then, the first time you can sign up for a Medicare Advantage is during the Initial Enrollment Period.

Your first enrollment period happens around the time you sign up for Medicare. After that, there’s an Annual Enrollment Period every year from October 15th-December 7th, and certain events may qualify you for a Special Enrollment Period.

Plans can change anytime, and most people notice more extreme plan changes when the new plan’s debut. Although, most people change coverage during AEP.

How is PPO different than an HMO?

Medicare Advantage PPOs and HMOs each have networks of healthcare providers. However, there are significant differences between the two. With an HMO, you don’t have coverage if you see a doctor outside of the plan’s network. This means you may pay the full cost of care.

A PPO beneficiary can see non-network providers; however, it costs more than staying within the network. HMOs usually operate with a network of local healthcare providers. Some PPOs may have broader networks.

In general, a PPO plan is likely to have a higher monthly premium than an HMO plan. Although, a PPO plan provides you with more flexibility.

The difference between a Medicare PPO and Original Medicare?

A Medicare Advantage plan must cover the same types of services as Original Medicare. Original Medicare is from the government; Medicare Advantage plans are sold by private insurance companies.

This means that the premiums and out of pocket costs for Medicare Advantage PPO plans may vary.

Unlike Medicare Advantage plans, traditional Medicare doesn’t have provider networks. You can see whatever healthcare provider you want, so long as the provider accepts Medicare.

Traditional Medicare Part B pays a standard 80 percent of medical costs, but you can reduce your out-of-pocket expenses by buying a supplemental Medigap plan.

You can’t get a Medigap plan if you have an advantage plan.

How to Enroll in a Medicare Advantage PPO Plan

Those looking for a portion of out of pocket coverage, with the lower price of an Advantage plan could benefit from a PPO. Advantage plans are great for beneficiaries under 65 on disability or for those with a limited income.

Some Special Needs Plans are available to beneficiaries with certain health issues.

Healthcare costs are rising, it’s important to find the right Medicare plan. MedicareFAQ can help by researching top insurance companies in your area and getting you free quotes on coverage.

Give us a call or fill out our form to start the comparison process. The best policy for you depends on your situation, call us to discover your best options.

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Jagger Esch

Lindsay Malzone is the Medicare expert for MedicareFAQ. She has been working in the Medicare industry since 2017. She is featured in many publications as well as writes regularly for other expert columns regarding Medicare. You can also find her over on our Medicare Channel on YouTube as well as contributing to our Medicare Community on Facebook.

4 thoughts on “Medicare Advantage PPO Plans

  1. Hello. I’m receiving conflicting information regarding a hospice patient who is in an Advantage plan who continues to pay monthly premiums for that plan while on hospice. Patient was on the plan before going on hospice. The issue is payment for medical treatment for conditions NOT RELATED to the terminal illness.

    According to the Medicare website and the publication CMS Product No. 02154, revised November 2020, pages 5 and 10 state:
    Page 5: “ IMPORTANT: if you were in a Medicare advantage plan before starting hospice care, and decide to stay in that plan, you can get covert services for any health problems that aren’t part of your terminal illness and related conditions. You can choose to get these from either your plan or original Medicare. For more information on hospice care if you’re in a Medicare advantage plan or other Medicare health plan, see page 10.“

    Page 10, paragraph 2: “If you were in a Medicare advantage plan before starting hospice care, you can stay in that plan as long as you pay your plans premiums. You can choose to get covered services for any health problems not related to your terminal illness from either your plan or original Medicare.” That seems pretty straightforward to me.

    The patient is my now deceased Mother. Each time I sought treatment of her for an unrelated condition, I made sure to make the providers aware that she was in hospice, HOWEVER, we wanted the Advantage Plan to be responsible for this care because it was not related to her hospice condition, so to please file the insurance forms appropriately.

    The Medicare publication, as well as their website, seem to make this point very clear. HOWEVER, she passed in Dec 2020 and I have been going round and round with United Healthcare and providers for 15 months as they insist Original Medicare is ALWAYS responsible for ALL treatments of hospice patient whether it was or was not related to her hospice condition. And the providers continue to send bills and even send the matters to collections. Medicare has told me twice on the phone that I am correct, and that they (Medicare) should not have paid for any of those charges. But UHC will not listen.

    I’ve written grievances/appeals to both Medicare and UHC. The response from UHC is that OriginalMedicare is responsible and the patient ( now deceased) is responsible for the remaining balance (“copay”). Noridian/CMS writes that she was in a Replacement Plan, but the plan will not pay when she had an open for hospice.

    This is SO FRUSTRATING and STRESSFUL!! What can I do? I feel like I’m just going in circles.

    1. Hi Linda! First off, I’m so sorry to hear about the passing of your mother. Medicare Advantage plans do have copays & coinsurance. Without seeing the bills, it would be hard to say for sure, but it seems like the bills coming from UHC are probably the coinsurance and/or copays left over after the Advantage plan paid their portion of your mothers’ medical costs for services received not related to hospice care. That’s one of the biggest disadvantages of Medicare Advantage plans, they choose how much of each service they want to cover. Original Medicare is not responsible for paying any medical bills that were not directly connected to her hospice care. Original Medicare is responsible for all her hospice care bills. UHC is responsible for THEIR portion of your mothers’ medical bills NOT associated with hospice. Then, your mother is responsible for any copays and/or coinsurance that fall under the Advantage plan for services NOT associated with hospice. I hope this helps!

  2. How is a medicare health plan with prescription drug coverage different from a medicare supplemental ins?

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