Thursday, June 16, 2022

What Is A Ppo Medicare Plan

Don't Miss

Is A Medicare Advantage Ppo Different From A Regular Ppo

Medicare Advantage Plan PPO (Preferred Provider Organization)

You may have heard the term PPO or used a PPO plan before you became eligible for Medicare. Thats because PPO plans arent limited to Medicare Advantage. PPOs are common types of health plans offered by private insurance companies such as United Healthcare and Aetna.

If youre familiar with using a PPO plan outside of Medicare Advantage, you can rest easy. A Medicare Advantage PPO plan works much the same way. The only difference is that instead of your employer covering part of the insurance cost, the federal government does.

Some Medicare Advantage PPO plans even offer benefits that arent typically included in non-Medicare PPO plans, such as dental care, eyeglasses, and wellness programs.

Medicare Advantage Ppo Plan Costs

If you enroll into a Medicare Advantage PPO Plan, costs associated with the plan include:

  • The Medicare Part B premium. You continue to pay this even when you get your benefits through a Medicare Advantage plan.
  • The monthly plan premium, if any, required by your Medicare Advantage plan. Some Medicare Advantage plans have a premium as low as $0 however, please note that even if your Medicare Advantage plan doesnt have a premium, you must continue to pay your Medicare Part B premium.
  • Deductibles, coinsurance, or copayments associated with the selected Medicare Advantage PPO plan.

*Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

Medicare information is everywhere. What is hard is knowing which information to trust. Because eHealths Medicare related content is compliant with CMS regulations, you can rest assured youre getting accurate information so you can make the right decisions for your coverage. Read more to learn about our Compliance Program.

How To Compare Medicare Advantage Plans

When comparing Medicare Advantage plans, you may want to look for the following features.

  • Prescription drug coverage: Many Medicare Advantage plans include coverage for prescription drugs or Medicare Part D. Most men and women who enroll in a Medicare Advantage plan look for Part D coverage. If youre interested in Part D coverage, be sure the plan you choose offers this benefit.
  • Additional benefits beyond original Medicare:In addition to Part D coverage, you may have additional benefits you prioritize. For example, if your family has a history of hearing loss, you may want to consider a Medicare Advantage plan that covers hearing aids and hearing exams.
  • Service area: Not every insurance provider is authorized to offer coverage in every state. Be sure to consider each plans service area before you enroll especially if you plan on moving within the year.

Recommended Reading: What Is Better Original Medicare Or Medicare Advantage

What Is A Medicare Advantage Ppo

Medicare Advantage plans are Medicare plans that are sold by private insurance companies. All Medicare Advantage plans cover Medicare Part A and Medicare Part B, and many also cover prescription drugs and other additional healthcare needs.

When you enroll in Medicare Advantage, youll need to choose a type of plan structure that matches your needs, like a PPO, HMO, PFFS, MSA, or SNP.

Anyone who is enrolled in original Medicare parts A and B is eligible to enroll in a Medicare PPO plan in the state they live in.

Medicare Advantage Ppo Plans

The Benefits of Medicare Advantage

A Medicare Advantage plan, or Medicare Part C, is an alternative to coverage with Original Medicare . Advantage plans are offered by private insurance companies who must follow Medicareâs rules. There are different types of Medicare Advantage plans, including:

  • Preferred Provider Organization Plans
  • Health Maintenance Organization Plans
  • Private Fee-for-Service Plans
  • Special Needs Plans

So how do PPO plans work? PPOs are managed care insurance plans that give you access to a select network of healthcare providers with discounted rates for plan members. This means that getting routine check-ups, annual appointments, and even hospital visits will cost less than going out of your network with another provider.

At a glance, PPO plans:

  • Have a relatively smaller network of healthcare providers
  • Offer lower costs for in-network services
  • Do not route care through a primary care physician

Unlike many HMOs, PPOs do not require you to choose a primary care physician, and you wonât need a referral to receive care from a specialist or a provider out of your planâs network.

With a PPO plan, you can see healthcare providers outside of your network for services PPOs cover. However, going out of your plan’s preferred network of hospitals, doctors, and specialists will usually cost more. Additionally, emergency and urgent care are always covered under Medicare Advantage plans.

Also Check: How To Apply For Medicare Insurance

What’s A Medicare Ppo Plan

A preferred provider organization plan gives you a financial incentive to select providers within the PPO network. That’s because the health insurer has negotiated contracts with PPO network providers to provide health services at discounted costs. You can go outside of the network for care, but you’ll pay more.

  • You don’t have to choose a PCP, although selecting one can help you coordinate care and help make sure your health care needs are taken care of.
  • You don’t need a referral to see a specialist, but you’ll have to make your own appointments with specialists and other health care providers.
  • You don’t need prior authorization for services to be covered outside of the network.
  • The amounts you pay toward your in-network deductible and your out-of-network deductible are combined. They don’t have to be reached separately.

Best For Concierge Service: Aetna

If youre hesitant about signing onto a health maintenance organization plan because youre afraid of accidentally going out of network, consider a plan from Aetna. Aetna offers medical concierge services that can help you find local resources and understand your coverage. All of Aetnas plans come with a $0 medical deductible and there is a $0 premium option for both HMO and preferred provider organization plans.

Aetna Medicare Advantage plans have some of the widest ranges of coverage available. Aetna offers both HMO and PPO plans. If you have a doctor or specialist that you want to stay with, you can save money by choosing a more flexible plan.

Aetna offers a limited selection of special needs plans in 12 states. Its plan benefits go beyond the services offered by Original Medicare and include local healthy living resources, prescription drug deliveries and SilverSneakers fitness membership programs.

Most plans also include vision and dental coverage options. With wide availability and 24/7 on-call nursing services, Aetna is one of the best Medicare Advantage providers for individualized plan solutions.

Don’t Miss: Can You Get Medicare Advantage Without Part B

Best In Educational Content: Aetna


  • Fewer plans available

  • No app available for payments

We like Aetna because of the care and tone it takes regarding educational information on its website. Before even getting into the particular coverage available, you have the option to learn more about the plan types , so that you can make well-informed decisions. Aetna also offers Dual-eligible Special Needs Plans for people who qualify for Medicare and Medicaid, which allow for the coverage offered by Original Medicare along with additional special benefits like non-emergency transportation, meal programs, over-the-counter medicine coverage, or help to stop smoking.

Searching for coverage and finding what you need is easy. Aetna offers the benefit of guiding you through the process to receive recommendations when you answer questions such as: ZIP code, what type of coverage needs you have, and any other health coverage options you are enrolled in. You can also manually review your options.

Not every plan type may be available in your location, so check your ZIP code through Aetnas website. Aetna offers a variety of plan types with a range of premiums.

Advantages Of Medicare Part C

Medicare HMO VS Medicare PPO – What Are The Differences?
  • More convenient premium: Medicare Part C combines the benefits of Part A and Part B coverage into a single convenient payment. This can make it easier to manage your healthcare costs and ensure that your premiums are always paid on schedule.
  • Enhanced benefits: Many Medicare Part C plan providers include Part D coverage rolled into its premiums, which is not included on the original Medicare. Insurance providers may also choose to extend additional benefits to Part C plan holders that are not included in Medicare parts A or B. Some examples of additional benefits may include dental care needs and hearing exams.
  • Streamlined medical care: Because many Medicare Part C providers offer all of their required medical services within a single network, your healthcare providers can actively communicate with one another regarding your treatment. This can help you avoid unnecessary complications and delays for example, interactions between medications provided by 2 different medical care professionals.
  • May save you more money: Most Medicare Part C plans include $0 monthly premiums and low to no deductibles. They also often limit the total amount of money youll need to pay out-of-pocket for the services you receive in a single year. This may save you money on your health needs when compared to what youd pay for original Medicare.

Recommended Reading: How Do I Apply For Medicare In Missouri

How Does A Ppo Plan Compare To Other Medicare Advantage Options

Weighing your options is easier when you can look at the plan types side by side. The chart below gives an overview of the two most common types of Medicare Advantage plans, PPOs and HMOs.


There are other types of Medicare Advantage plans, but they are far less common. These options include Private Fee-For-Service plans, Medical Savings Account plans, and Special Needs Plans . For a full overview, see our Medicare Advantage Plans Guide.

How Much Does A Medicare Ppo Plan Cost

The cost of a Medicare PPO plan will vary greatly based on location, insurer, and coverage included. Some Medicare Part C PPO plans offer the minimum required coverage, that is, Medicare Part A and Part B benefits. In contrast, others include a vast array of coverage options, such as travel insurance, vision and dental insurance, prescription drug coverage, and hearing coverage. The more coverage included in a plan, the more it costs.

No two PPO plans are identical. In areas with large markets, you may have dozens of plans to consider, each at a different price point. This allows for increased flexibility. If you have limited medical needs and no interest in extended coverage, a PPO plan with a lower monthly premium may suit you.

There are other costs to consider. Medicare Part B can affect the cost of a Medicare PPO plan. Some plans may cover a portion of the cost of Medicare Part B in Medicare Advantage premiums, but this isnt universal. If Plan B premiums are not covered, you will still be required to pay these costs on top of your PPO plan premiums. Consider the impact of out-of-pocket expenses, such as deductibles, when evaluating total plan costs. Some PPO plans may have a deductible associated with the prescription drug coverage aspect of the plan, as well as an additional premium. If you choose a PPO, you cannot buy a separate prescription drug plan.

Also Check: When Can I Enroll For Medicare Part B

Medicare Advantage Hmo Vs Ppo Plans: How Theyre Different

Medicare Advantage HMO plans and PPO plans are probably more alike than different. But there are a few HMO vs. PPO contrasts:

  • Although they generally have provider networks, Medicare Advantage PPOs let you see doctors outside the plan network. You might have to pay higher coinsurance or copayments for seeing out-of-network providers.
  • You dont have to choose a primary care provider with a Medicare PPO, but you do with an HMO.
  • If you want to see a specialist, an HMO generally requires you to get a referral. A PPO typically lets you see a specialist without a referral.

Although Medicare Advantage PPO plans may offer more flexibility, your costs are generally higher under a PPO.

You might need to take a more active role in care coordination in a PPO plan. For example, if you see providers outside the Medicare Advantage PPO plans network, you may have to give information about the medical care you have received and your prescription drugs to doctors who treat you.

With any type of Medicare Advantage plan, youll need to keep paying your Medicare Part B monthly premium, as well as any premium the plan might charge.

The pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year.

New To Medicare?

How Are Hmo And Ppo Plans Similar

CA Medicare

Despite their differences, HMO and PPO Medicare Advantage plans have a lot in common.

Both types of Medicare Advantage plans provide the same basic coverage as Medicare Part A and Part B into one single plan.

Many Medicare HMO and Medicare PPO plans may also include additional benefits not covered by Original Medicare.

Some of these additional benefits can include:

Some Medicare Advantage plans may offer even more additional benefits. These benefits can vary based on your location and the plan provider.

You May Like: How Much Is Medicare Copay For A Doctor’s Visit

When Can I Enroll In A Medicare Advantage Plan

You can join a Medicare Advantage Plan during the following periods.

  • Initial enrollment period: You can enroll in a Medicare Advantage plan the month that you become eligible for original Medicare coverage. In most cases, this is when you turn 65.
  • Open enrollment period:From Oct. 15 to Dec. 7 each year, you can join, switch or drop a Medicare Advantage plan. If you enroll during this period, your coverage will begin on January 1st of the next year so long as your application is processed before Dec. 7.

If you have a current Medicare Advantage plan and you want to switch to a different plan or to original Medicare coverage, you can do so from Jan. 1 to March 31 each year.

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 dont have coverage if you see a doctor outside of the plans 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.

Read Also: How Can I Get My Medicare Card Number

What Is The Difference Between Hmo And Ppo Insurance Plans

Both HMOs and PPOs have contracted networks of healthcare providers, clinics and hospitals where they will pay for some or all of your care. However, there are differences to consider:

  • First, HMOs and PPOs treat their out of network costs differently.
  • With an HMO, if you go out-of-network to see a provider, they may not cover any of your costs. Unless, it is an emergency situation.
  • With a PPO, the plan will most likely cover out-of-network provider/hospital visits, but at a lower percentage rate than their in-network providers/hospitals.
  • Second, the networks treat visits to healthcare specialists differently.
  • With an HMO, you will often need a referral to see a specialist.
  • With a PPO, you can most often just choose a specialist from the network provider list and make an appointment to see them without a referral.
  • Third, the PCP is usually the person making referrals in an HMO network. As a result,
  • The HMOs often require having a primary care physician on file for its members.
  • While the PPOs usually do not have a requirement to name a PCP.

Hmo Vs Ppo Which Is Better

Differences between Medicare PPO & HMO Plans


  • HMO vs PPO Which is Better Summary
  • Insurance has changed a lot over the last 20 years, and there is no better example than the way we define and use provider networks. When you are looking at insurance plans, its important to compare HMO vs PPO. Which is better for you?

    We are here to clear up the confusion, and quickly answer the most frequently asked questions in regards to what is HMO and PPO insurance, how the plans work, and where you will find HMO and PPO insurance plans.

    If you are a Medicare user, you will run into HMO vs PPO in regards to choosing a Medicare Advantage Plan. You can learn more about Medicare Advantage Plans here.

    Don’t Miss: How To Get A Lift Chair From Medicare

    What Is Medicare Ppo / What Is Medicare Hmo

    PPOs and HMOs come into play in Medicare when you are using Medicare Part C aka Medicare Advantage Plans.

    Medicare Advantage Plans are alternative plans offered by private insurance companies to take the place of Original Medicare. They often include drug coverage or Part D coverage . They are approved by the Federal Government and cover everything that Original Medicare covers. In addition, they often offer benefits and services beyond what Medicare offers such as dental, vision and hearing benefits.

    So then, what is a Medicare Advantage PPO plan or HMO plan?

    Medicare Advantage plans are often HMO, PPO, or PFFS plans. When you are choosing a Medicare Advantage Plan, you will need to consider everything we discussed about HMOs and PPOs as they will apply to these private insurance plans and how they set-up their provider networks.

    More articles

    Popular Articles