PPO Plans

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Medicare PPO Plan Overview

Medicare PPO stands for Preferred Provider Organization, and this means that the insurance company has a network of providers that you are able to see. You may see doctors outside of your network, but you will find that out-of-pocket spending is much higher.

What is a Medicare PPO?

A Medicare PPO is a type of Medicare Advantage plan that is available as an alternative to Original Medicare. By joining a PPO, you will have lower co-pays when seeing providers in your network. Every plan is different and has its own rules, but usually, you do not have to choose a primary care doctor or get referrals to see a specialist.
A Medicare Advantage PPO will provide Medicare part A and B benefits to you, and it will include an out-of-pocket maximum. In 2020, that out-of-pocket maximum is $6.700 per calendar year. This cap protects you in the event that your medical costs for the year are greater than you expected.

Common Features of Medicare PPOs

  • You may see out-of-network providers, though it will be at a higher cost.
  • You may enjoy lower premiums than a Medicare Supplement Plan because you agree to the plan’s rules and restrictions.
  • Usually, Medicare Part D benefits are included. Please note that if you choose a Medicare PPO plan with medical benefits only, you may not have a separate Part D drug plan. You MUST choose a plan that includes Part D to get prescription drug coverage on a PPO plan.
  • Some plans include benefits for vision exams, discounts on gym memberships, and more. Restrictions and co-payments may apply.
  • Every September, you will be mailed an Annual Notice of Change letter from your insurance company. This letter is very important to read and review. It will notify you of any changes coming to the policy, including benefits formulary, pharmacy network, provider network, premiums, co-pays, and coinsurance, etc. These changes take place on January 1 of each year. After reviewing your Annual Notice of Change letter, you can decide if you need to make any changes to your coverage.

Costs Incurred on a Medicare PPO plan

When you enroll in a PPO plan, here are some of the expenses you can expect…
  • You will have to pay for Medicare Part B, which is $144.60 per month in 2020. If you have a higher income, you may expect to pay more.
  • You will pay your monthly premium for your Medicare PPO plan. Some plans have a $0 premium, but even if that is the case, your premium can change each year.
  • You will have co-pays for medical services as you receive them, and you will usually have to pay a hospital co-pay for hospital visits. Every plan will outline exactly what you will be financially responsible for in the Summary of Benefits document, and we can help review this with you.
  • If you see an out-of-network healthcare provider, the cost will be higher and you may have to pay a deductible up-front.
  • Most of the time, Part D drug plans are built into the PPO plan, so you will not be paying separately for a prescription drug plan.

Medigap or PPO?

Some people will ask if a Medicare Supplement (or Medigap) plan or a Medicare Advantage plan is better. The answer is that it all depends on your own preferences. With a Medicare Supplement plan, you will likely be paying a higher premium, but out-of-pocket costs are very low. You often are not even responsible for a doctor co-pay.
Medicare PPO plans provide you with a lower monthly premium, but you will have things to pay out-of-pocket, such as co-pays for doctor visits, lab work, hospital stays, and surgeries. Some people prefer to pay as they go and enjoy the lower monthly premium.

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