A Medicare PPO plan is a kind of Medicare Advantage plan that you can enroll in as a private alternative to Original Medicare. The name Medicare PPO stands for Preferred Provider Organization. It means that the insurance carrier has a network of health providers that will coordinate your care at negotiated contract rates.
Our licensed Medicare agents are here to inform you about each Medicare Advantage plan so you can decide what is suitable for you.
You Pay Lower Copays
In a Medicare PPO, you’ll normally pay lower copays if you visit providers that are in the network. Usually, you’re not required to select a primary care physician or get referrals to visit specialists. But each plan has its own set of rules, so be sure to check the summary of benefits before you enroll.
The Plan Includes an Out-of-Pocket Maximum
A PPO is required to provide your Original Medicare benefits to you under the plan. Also, the plan must include an out-of-pocket maximum limit on your spending. This ceiling protects you against fateful spending during a year when you’re enduring unusually hefty medical expenses.
In 2022, the most that any Medicare Advantage plan can post as your out-of-pocket max is $7,550 per calendar year. So, at worst you’d pay that $7,550 out-of-pocket on hospital and outpatient costs.
Some of the features of Medicare PPOs
- Freedom to visit out-of-network doctors at a higher cost.
- Premiums might be lower than a Medicare supplement plan since you agree to the plan’s rules and restrictions.
- Part D drug plan benefits are normally included. Note that if you have a PPO with medical benefits only, you can’t have a separate Part D drug plan. To get drug coverage for a Medicare PPO plan, you must select one with a concentrated Part D plan.
- Some plans may include additional benefits for vision exams or discounts on gym memberships. Certain limitations and copayments may apply.
- Annual changes – The benefits formulary, provider network, pharmacy network, premium and/or copayments might change on January 1 of each year. Review the plan changes from year to year to decide whether you have to make changes to your coverage.
Common Costs You May Incur on Medicare PPO Plans
When you join a Medicare PPO plan, you may have the following types of expenses:
- You’ll still pay for Medicare Part B, which is $170.10 per month in 2022.
- Plan members with higher incomes may pay more.
- You’ll pay a monthly premium for the PPO plan itself. Some plans may have a $0 premium, although it depends on the plan. The premium can also change from year to year.
- You’ll pay copays for medical services as you go. You might pay $25 for a primary care visit or $60 to see a specialist. The hospital copay may be daily or it could be larger for the whole stay. For a service like chemotherapy, you’ll pay 20%.
- Out-of-network costs might be higher and may require an up-front deductible.
Each plan will summarize its particular set of benefits and copays in the Summary of Benefits page. An insurance agent at Cornerstone Senior Advisors can discuss this with you.
Is Medicare PPO Better Than Medigap?
If you’re new to Medicare, you may wonder which is better — Medicare supplements or Medicare Advantage plans like PPOs? It comes down to your personal preferences.
Medicare supplements, aka Medigap plans, pay after Medicare and leave you with a sliver of out-of-pocket costs. You won’t even have a doctor copay most of the time! But, they’re normally pricier than Medicare PPO plans.
On the other hand, Medicare PPO plans will normally have lower premiums. But you consent to use a network of doctors to obtain the best copays. You’ll pay as you go, so there will be copays acquired from you at the time of each service. This includes lab-work, surgeries, doctor visits, hospital stays, durable medical equipment, etc. Some folks are okay with this because they favor a lower monthly premium. It’s totally up to you.
Do I Still Pay for Part B on a Medicare PPO?
Yes. You must be enrolled in both Parts A and B and reside in the plan’s service area to be eligible for a Medicare Advantage PPO plan.
Choosing a plan can be complicated. It’s critical to ensure that you’ll have access to the healthcare providers and medications that you need. We’re a licensed agency that specializes in Medicare plans, and we can perform this research for you free of charge.
After you enroll through us, we’ll assist you when you have questions about how your benefits will cover certain services or claims. Call Cornerstone Senior Advisors to determine whether a Medicare PPO plan would be sufficient for you. You can reach us at (316) 260-3331!
