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Medicare PPO Plans

Medicare Advantage PPO Plan

Medicare Advantage PPO Plan

A Medicare Advantage PPO Plan (Medicare Part C) or a preferred Provider Organization Plan is available through private insurance company contracted through Medicare to provide benefits for beneficiaries. Medicare PPOs must offer all Medicare Part A and Part B benefits. They also offer Medicare Part D benefits.

Part A is the Medicare inpatient hospital insurance. The Part B covers the Medicare Outpatient insurance. Part D is the Medicare’s outpatient prescription drug benefit. If you choose a Medicare Advantage plan all your medical care comes from the plan; Medicare will not provide any benefits. Some plans may offer additional coverage such as vision and dental care not offered by Original Medicare.

Each PPO plan has its own network of hospitals and doctors. Individuals that are enrolled in Medicare PPO plan are allowed to use services out of the network but usually for a higher cost.

Generally, you can receive healthcare from any doctor or hospital in the PPO plan without the need for referrals. While you will usually pay more, you have the flexibility to see any doctor, hospitals or specialists that aren’t on the plan’s list and are willing to accept payment from the insurance company.

To enjoy the lowest cost, in a Medicare PPO, you must use the service of providers in the PPO’s network. In a PPO, you can see specialists without referral from your Primary Care Physician. PPOs are also limited on how much they can charge you for copays.

Plans need to have an out-of-pocket limit on how much you can pay. They have two different out-of-pocket limits for in and out-of-network care. While the out-of-network casts can be higher they will limit your expense from excessive costs if you use expensive treatments.

Comparing a HMO Plan with an PPO Plan

HMO plans and PPO plans offer the same medical benefits, but there are some differences you should know.

PPO plans are generally more expensive than HMO plans both for monthly premium and copays, but they give you more flexibility and a larger choice of doctors and hospitals. You will also enjoy the ability to see specialists without a “gatekeeper” to authorize referrals. And it’s important that if needed you are able to go out-of-network to see the provider of your choice.

HMO plans are usually more affordable, but they tend to have a smaller network and restrictions. You must use the network of doctors and hospitals. If you choose to do otherwise, you will not be covered except for emergency urgent care.

To take advantage of the savings attached to your PPO plans, you are advised to choose a doctor within your network for routine care except for urgent care situations which may cost higher. Facilities and specialists rarely require referrals from your Primary Care Physician (PCP).

The provider network may change anytime but you will be updated when necessary. This information is not a complete description of benefits you get from PPO plans. Copayments, limitations and restrictions may apply. Premiums, benefits and/or member cost-share may change on January 1st of each year.

For more information about our PPO plans, please feel free to contact with one of our plan representatives. We look forward to hearing from you!

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