Medicare Advantage PPO plans offer Medicare benefits through insurance companies and are widely available..
A Medicare Advantage PPO plan is one of the four types of Medicare Advantage Plans. Medicare Advantage Plans are also referred to as Medicare Part C, which includes coverage for Original Medicare Parts A and B. Some Medicare Advantage PPO plans also provide Part D prescription drug coverage.
All PPO plans must cover the same benefits as Original Medicare Part A and Part B. How you pay for your portion of costs for services looks different. For instance, if you require hospitalization, your PPO charges you a daily copay for a certain number of days. Original Medicare Part A charges a deductible for each benefit period.
Coverage for Part A and B includes:
PPO plans also typically include services which are not covered by Medicare:
How the plan works
With a Medicare Advantage PPO Plan, an insurance company manages your health care services through a group of preferred healthcare providers and medical facilities. This is called in-network care. You can choose to receive out-of-network services, but your out-of-pocket costs will be higher.
|Advantages of a Medicare Advantage PPO Plan||Disadvantages of a Medicare Advantage PPO Plan|
|PPO plans are growing in popularity among Medicare recipients. Here are some reasons why:
||Here are some of the disadvantages of Medicare Advantage PPO plans:
A Medicare Advantage PPO plan might be a good fit if you:
|Plan type||Costs||Part A coverage||Part B coverage||Part D coverage||Out-of-state care|
|Original Medicare||Part B premium||Yes||Yes||No||Yes|
|Medicare Advantage HMO||Part B premium plus plan premium||Yes||Yes||Usually||Emergency only|
|Medicare Advantage PPO||Part B premium plus plan premium||Yes||Yes||Usually||Emergency, plus other care if in your plan’s network, or you pay more for out of network|
|Medicare Advantage PFFS||Part B premium plus plan premium||Yes||Yes||Sometimes||Emergency, plus other care if contracted with your plan and agrees to treat you.|
|Medicare Advantage SNP||Part B premium||Yes||Yes||Yes||Emergency and out-of-area dialysis plus other care if in your plan’s network|
You need to meet the following criteria to qualify for a Medicare Advantage PPO plan:
Expect to pay about $190 per month for your Medicare Advantage PPO plan. That includes the typical $170.10 Part B premium and an average plan cost of $19. You’ll have additional costs when you use your coverage, including:
Costs vary from state to state, so it’s important to compare the plans available in your area for an accurate cost estimate.
See how costs compare for these PPO plans in Denver County, CO (plans include drug coverage):
|Plan name||Monthly premium||Deductible||Copay||Coinsurance||Out-of-pocket max|
|Aetna Medicare Prime 1||$0||$0 (health and drug)||PCP: $0
|40%||$5,300 in network
$11,300 in and out of network combined
|Anthem Mediblue Access||$0||$0 (health and drug)||PCP: $0
|40%||$6,700 in network
$10,000 in and out of network combined
|HumanaChoice H5216-261||$0||$0 (health)
|50%||$6,700 in network
$11,300 in and out of network combined
To enroll in a Medicare Advantage Plan, you first need to be enrolled in Original Medicare Part A and Part B. After you’re enrolled in Original Medicare, you can enroll in a PPO plan during your Initial Enrollment Period or during other enrollment periods throughout the year:
Use the Medicare Plan finder to research available PPO plans in your area. When you’ve chosen a plan, go to the insurer’s website to check for online enrollment options or contact the insurance company by phone or email to request a paper enrollment form. You can also enroll by calling Medicare at 1-800-633-4227.
To enroll, you need your Medicare number and the date your Parts A and B coverage began. Your Medicare card has this information.
Roseann Birch has worked in the insurance industry for more than 35 years. In 2006, she moved to selling insurance and, by 2009, Birch made Medicare her area of expertise after observing the struggles of older adults to understand Medicare. Although many adults age 65 and older are eligible for Medicare, nearly just as many don’t understand how it works.
Birch has learned the ins and outs of Medicare and its variations and supplements to help beneficiaries and their families understand benefits. She finds there is often misinformation and makes it her mission to clear up the confusion so that everyone can enjoy the full extent of Medicare benefits.