A Medicare Advantage PPO Plan is a type of Medicare Advantage Plan (Part C) offered by a private insurance company. The term PPO stands for Preferred Provider Organization. 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.

Medicare Advantage Preferred Provider Organizations (PPOs) are private companies that the federal government pays to administer Medicare benefits. Like all Medicare Advantage Plans, PPOs must provide you with the same benefits, rights, and protections as Original Medicare, but they may do so with different rules, restrictions, and costs. Some PPOs offer additional benefits, such as vision and hearing care. 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 2019, 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.

  • Freedom to see out-of-network doctors and medical providers at a higher cost
  • One Health Question – Medicare Advantage PPO’s only have one health underwriting question. Are you receiving Routine Dialysis for Kidney Failure?
  • Premiums Are Lower than Supplement plans – Some plans have a $0 premium. However, premiums can change from year so it’s important to always review your Annual Notice of Change letter each fall.
  • Pay When You Use the Plan – Pay as you go in the form of co-pays or coinsurance. Each plan has a benefit summary which will tell you how much the provider is allowed to charge for certain services. Co-pays vary for services like doctor’s visits, lab-work, and inpatient hospital care
  • Some plans may include “extra” benefits for things such vision exams or discounted gym memberships.
  • Prescription Drug Plan – are included in many PPO plans. In most cases, your drug formulary is included in their drug plan.
  • Annual Notice of Change – each year you receive an AOC from the plan, this is also known as the Annual Notice of Change. This letter will tell you the upcoming changes in the Medicare PPO plan for the next year. The premium and/or co-payments, co-insurance, benefits formulary, pharmacy network, provider network, may change on January 1 of each year. Reviewing your plan from year to year is important and a necessary duty.

At Nevada Medicare, we analyze, assess, and review your plans every year so that you are informed of the changes and show you what your options are. Our forensic plan analysis and consultation is at No Cost to you. If you need clarifications on how an PPO may work for you, Contact Us today.

  • You will still pay for Medicare Part B, which is $144.60/month in 2020. Some people pay more due to higher incomes.
  • You will pay a monthly premium for the Medicare Advantage PPO plan itself. Some plans may offer a $0 premium, but it depends on the plan and this can change from year to year as well.
  • Co-pays for medical services: You might pay $20 for a primary care visit or $50 for a specialist. You’ll usually pay a hospital copay that may be daily or could be one large co-pay for the entire stay. Often there are some services where you will pay 20%. This is commonly seen for chemotherapy. However, every plan will outline its specific set of benefits and co-pays in the Summary of Benefits document.
  • Out-of-network costs may be higher
  • Part D drug plans are often built into the plan, so you will generally not have any additional costs for Part D.

Which is better? Medicare Supplements or Medicare Advantage plans like PPOs?

Choosing the right Medicare Advantage plan is on a case to case basis. Medicare supplements 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 Advantage PPO plans will generally have lower premiums, but you agree to use a network of doctors to get the best co-pays. You will pay as you use the plan, so there will be co-pays 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.

So, In Summary, the main difference with Medicare Supplement vs Medicare Advantage when it comes to cost are:

    1. Medicare Supplement: You pay every month whether you use the plan or not. Supplements have a much higher premium than any plans in Medicare.
    2. Medicare Advantage: You keep your money and sometimes pay nothing to have the plan. You only pay when you use the plan, but you do have a safety net each year called Maximum-Out-of-Pocket.

Let us do the hard work everyday, while you live and enjoy the more important aspects of your lifetime. Contact Us our help is free.

Yes, you have to continue paying for Part B. Everyone pays for Part B, regardless of what plan you select. 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 Advantage PPO plans is another option you have for your Medicare coverage. They are not the same as Medicare Supplements.

Be cautious, selecting a plan is risky. You want absolute certainty that you will have access to the healthcare providers and medications that you require. At Nevada Medicare we specialize in Medicare plans and can do this research for you at no cost. After you enroll through, we can provide support to you when you have questions about how your benefits will pay for certain services or claims.

Our Medicare licensed agents can breakthrough the ever confusion and errors that happens frequently with Medicare beneficiaries. We know this because we hear it from folks like you everyday.

 

Let us do the hard work everyday, while you live and enjoy the more important aspects of your lifetime. Contact Us our help is free.