What’s a Medicare Advantage PPO and how does it work?
A Preferred Provider Organization (PPO) is a medical insurance plan that uses a network of providers (doctors, hospitals, etc.) to provide medical coverage. Unlike an HMO, in a PPO you don’t have to see your primary care physician (PCP) before you see a specialist. Additionally, you can see providers outside of the network. However, out-of-network providers may charge higher fees.
Several features make Medicare Advantage PPOs a popular choice:
- Out-of-network coverage
- Ability to see specialists without referral from primary care doctor
- PPOs may offer additional benefits like dental and vision coverage plus health and fitness incentives
As an example, 4% of Medicare eligibles in Maricopa are on PPO plans. Most carriers offer at least one plan with a $0 monthly premium.
A Medicare PPO can help control cost and maintain flexibility. Below you can find a guide on how to compare the different plans.
Obviously, choosing your Medicare coverage is an important decision. You should discuss your options with a licensed advocate who can help you make the best choice.
Some things you need to consider:
Which doctors can you see?
Year after year, studies show that people like you are most concerned about which doctors they see. In fact, many people will sacrifice other parts of their coverage to see doctors they are comfortable with and who know their medical history.
Medicare Advantage PPO plans offer you greater choice of providers plus the option of going outside the network. If you decide to see a provider not in the plan’s network, you will pay more. The amount you will pay varies by plan, so make sure you are familiar with the charges for in and out of network providers.
Check the list of providers for each plan to see if your doctors are listed. Most doctors contract with multiple insurance plans, so you may be able to find a plan your current doctor accepts.
Remember, like any other business, providers may decide to leave a certain practice, stop accepting a certain insurance plan or retire. Therefore, it is important to choose a network that has your providers and also has a large selection of other providers in your area. Be sure to have our staff help optimize that selection.
Consider choosing doctors and facilities who are preferred cost-share or value-based providers. Insurance companies partner with these providers to help improve positive outcomes for their members and save money. Your plan may offer lower office visit copays for these providers. Our team is happy to speak with you about the different value based providers in Arizona.
What to consider when looking at a plan’s network
|Less Desirable Network||More Desirable Network|
|Your Doctors||Not in network||In network & many options in case you need to switch|
|Your Pharmacy||Not preferred||Preferred|
|Urgent Care||Limited availability near you||24/7 urgent care near you|
|Hospitals||Limited choice of hospitals||All hospitals accepting Medicare|
How much will a Medicare Advantage PPO plan cost?
Premiums vary for Medicare Advantage PPO plans, and not all insurance carriers offer these plans in Arizona. The good news is that some carriers offer a $0 premium plan in Arizona and some offer low or no copays on Primary Care Doctors.
When you compare plans, it is important to understand the difference between two key components:
- Deductible: What you pay for medical and/or prescription drugs before your insurance begins to pay for coverage.
- Maximum Out of Pocket (MOOP): The maximum amount you will pay out of pocket in a given year.
Another key component of your cost is prescription drug coverage, which can vary from plan to plan. Different plans may cover drugs at different rates and tiers. Drug prices can also differ depending on which pharmacy you use to purchase your medications. But not to worry, our team is here for you to help optimize your prescription drug costs.
Another factor in what you pay for prescription drugs is the Medicare drug coverage gap. Commonly referred to as the “donut hole.” Please read our guide on coverage gap and our team can also walk you through the details.
Our team is here to walk you through the different cost tradeoffs based on your personal situation. Optimizing your coverage can lead to significant savings.
Key Differences Between Higher and Lower Cost Plans
|Higher Cost||Lower Cost|
|Monthly Premium||More than $40||Low or no|
|Primary Care Provider||More than $40||Low or no|
|Specialist||$40 - $50||$30 - $40|
|MOOP||More than $6000||Less than $5000|
|Rx (Deductible)||More than $150||$0|
What about other Medicare benefits?
Recently, insurance carriers have included additional health-related benefits in Medicare Advantage policies. It’s easy to understand why. A healthier lifestyle reduces medical costs. The insurance provider and the insured both benefit.
Popular additional benefits included in Medicare Advantage include:
- Over-the-counter items like toothbrushes, vitamins, medical supplies and fitness monitors
- Gym memberships
These benefits can vary widely between different plans and carriers.
Here are some considerations to take into account when evaluating a plan:
Dental coverage may include routine preventative services (twice yearly cleaning, exam and x-rays), comprehensive care (minor, restorative and major services) or both.
Vision and hearing coverage is usually for routine services–typically an annual exam. Materials such as hearing aids, glasses and contacts may be partly covered as well.
Coverage of over-the-counter health products like electric toothbrushes, vitamins, medical supplies and fitness monitors is becoming increasingly popular. This is usually a quarterly allowance which may either roll over (if not used) or be “use it or lose it.”
Gym memberships like Silver Sneakers, Silver and Fit or Renew Active may be offered. Most plans offer this at no extra cost. Check if your favorite gym is covered and if extra classes, like watr aerobics and cycling classes, are covered.
Remember, these added benefits are a “win-win” for you and your insurance carrier. They save money by keeping you healthier. You get coverage and services beyond traditional Medicare and save money on things you may already pay for out of pocket.
Review these additional benefits with your Connie advocate and choose a Medicare PPO plan with the best combination of benefits for you.
|Limited Benefits||Expansive Benefits|
|Dental||No allowance||$500 or more for preventative|
|Vision||No allowance||$100 or more towards glasses/contacts|
|Hearing||Medicare covered exams cost $20 or more||Medicare covered exams cost $0|
|OTC||$0||$50 or more every quarter|
|Gym||Don't have a gym near you||Has the gym you go to|
Make the Right Decision for You
There are many factors you need to consider when choosing a Medicare Advantage PPO plan. Above we have highlighted some important factors for you to consider, however we realize each person has their own personal needs. When you meet with our team be open about your healthcare, financial needs and preferences so can help you find the right solution for you.
Making the right decision might seem challenging given the complexity of Medicare and the choice overload. However our local team is here to help, at no additional cost to you. It is our job to make sure whatever decision you make is stress free and you walk away with full understanding of your selection. Furthermore, we will continue to help you and your family throughout your healthcare journey, serving as a trusted advocate for many years to come.
Learn more about Medicare
Visit our Medicare Resource Center which provides helpful articles on everything you need to know about Medicare.