A Medicare PPO Plan is a Medicare Advantage Plan where a Private Insurance company provides your Medicare Part A and Part B benefits. In a Medicare PPO Plan, you can get Medical Services from any provider who accepts Medicare. The Medicare PPO has a preferred network of providers “in network” where cost sharing is lower. Other providers are “out of network”. Cost sharing is generally higher for “out of network” providers. Premiums will vary depending on the plans available in your area. Depending on the plans available in your area, some of the plans may include Dental, Vision, Hearing, Gym Memberships. Additionally, some plans may include a Maximum out of Pocket which would put a cap on your financial exposure in a calendar year. This option would include no Medicare Prescription Drug benefit.
Is this option right for me?
•If you have other supplementary coverage for Prescription Drug coverage (for example, VA Drug benefits), this could be a good choice.
•If you enjoy value added benefits, like hearing, vision, dental, gym memberships, this could be a good choice.
•If you like having care coordination services to assist you with a chronic condition, this could be a good choice.
•If you prefer a lower fixed monthly premium with higher cost sharing when you need to access benefits to a higher fixed monthly premium with lower cost sharing, this could be a good choice.
•If you value the freedom of being able to choose out of network providers in special circumstances, this could be a good choice.
•If you are satisfied with the Provider network for your basic healthcare needs, this could be a good choice.
•Financial Exposure to Part A and Part B cost sharing can be capped depending on the specifics of the plans in your area.
•Premium can be lower than a Medicare Supplement depending on the specifics of the plans in your area.
•Freedom to use “out of network” providers at a higher cost share.
•Additional Value Added benefits may be available (like Dental, Vision, Hearing and Gym benefits) depending on the specifics of the plans in your area.
•Not having a Medicare Prescription Drug benefit means that the premium you pay will generally be less than a plan which would include the drug benefits.
•Unknown Out of Pocket costs depending on your level of utilization of services in the Medicare PPO plan.
•Medicare Advantage plans are not Guaranteed Renewable like Medicare Supplement plans. In addition, the benefits can be changed on a calendar year basis.
•Unlimited financial exposure for Part D Prescription drug expenses.
•Late Enrollment Penalty would apply for Medicare Prescription Drug benefit unless there is other Creditable coverage.
Costs — Medical and Hospital
•Premium for the Medicare PPO plan will vary based on the county of your residence and the plan you choose to enroll in.
•Generally, there is cost sharing for Hospitalization, Doctor Office visits, diagnostic tests, x-ray, therapy, etc. The cost sharing would differ depending on whether you are seeing an “in network” provider or an “out of network” provider. You will need to review the Summary of Benefits for each of the specific plans in your area to determine the exact out of pocket costs.
•Some plans may also include a Maximum out of Pocket limit which is a calendar year maximum.