What is a Medicare Advantage PPO plan?

Private insurance companies offer Medicare Advantage PPO plans. This is what Original Medicare considers a Part C plan. PPO plans have their own networks of doctors and hospitals. You pay less if you use an in-network doctor or service but you may still see an out-of-network doctor but usually at a higher cost. Just like with a PFFS plan, you don’t have to choose a primary care doctor so you won’t have to get a referral to see a specialist. Most PPO plans include Part D prescription drug coverage but since all plans offer different coverage, be sure to check that the drugs you use are covered before you enroll.

Benefits of a Medicare Advantage PPO

  • You don’t need a primary care doctor. In most cases, you have network doctors and hospitals. You can see doctors and specialists not in the plan but they usually cost more because they’re out of network.
  • Most plans have Part D prescription drug coverage. So if you’re looking for prescription drug coverage, you must join a PPO plan that offers Medicare drug coverage. If your plan doesn’t have prescription drug coverage, you can’t join a Medicare Prescription Drug Plan (Part D).
  • You don’t need a referral to see a specialist. If you do see a specialist, staying within your plan’s network is the best way to keep costs down. But there is no limit to seeing any doctor.
  • May see out-of-network doctors, but at a higher cost. PPO health plans offer coverage for out-of-network providers, but staying in your network keeps your costs lower. You will pay more by seeing an out-of-network doctor.
  • Some plans have extra benefits. Original Medicare usually doesn’t cover routine eye exams or prescription eye glasses. But with PPO plans you may have that covered. PPO plans may also cover dental care, hearing exams, even gym memberships and weight management counseling.

What are the costs of a Medicare PPO Plan?

  • You usually pay a monthly premium for your Medicare Advantage Plan, along with what you pay for your monthly Part B premium.
  • There may be copayments and coinsurance for services. Every cost and coverage will change based on the plan you choose.
  • There is a limit on your out-of-pocket costs. Once that limit has been reached, you won’t have to pay for covered services the rest of the year.
  • Many times out-of-pocket costs are lower in an Medicare Advantage plan. If that is the case with the PPO plan you choose, this may be the best option for you.

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