Medicare Advantage PPO Plans
PPO plans, which stand for Preferred Provider Organization Plans, are highly favored among managed care Medicare Advantage plans due to their lower cost and greater flexibility in choosing medical providers. However, if beneficiaries opt for healthcare providers outside the PPO network, they will have to pay more out-of-pocket expenses. It’s worth noting that private insurance companies offer all Medicare Advantage plans, including PPO.
While Medicare Advantage plans, including PPO, cover hospital and medical insurance that are typically part of Original Medicare Parts A and B, they also offer additional benefits such as hearing, dental, and vision services.
PPO Plan Key Takeaways
PPO Plans allow beneficiaries to seek medical care outside of the provided network, but they should expect to pay more out-of-pocket expenses if they do. This is in contrast to HMO Plans, which are another popular Medicare Advantage plan, as PPO beneficiaries don’t need to select a primary care physician or obtain specialist referrals. However, it’s recommended that they remain within the network to avoid additional costs.
As previously mentioned, every Medicare Advantage plan, including PPO, is required to cover benefits included in Parts A and B. In addition, beneficiaries are provided with other benefits such as prescription drug coverage (including over-the-counter drugs), dental, vision, and hearing coverage, fitness benefits through SilverSneakers, meal delivery after an inpatient hospital or skilled nursing facility stay, transportation to medical appointments, adult day-care services, and nutrition and wellness programs.
All Medicare Advantage plans come with deductibles, copays, or coinsurance requirements for any received services. While most Medicare Advantage plans have no monthly premiums, including PPO plans, each plan still has a maximum out-of-pocket limit that policyholders must be aware of. Once policyholders reach this limit, their provider must cover all costs for the rest of the year. For PPO plans in 2023, the maximum out-of-pocket limit is set at $8300 for in-network services and $12 450 for out-of-network services. It’s important to note that since private insurance companies offer PPO plans, the cost of each plan can vary depending on the insurance company and service area, and ZIP code.
Is PPO a Good Option?
If you are looking for the freedom to visit any doctor and hospital, as well as see specialists without requiring a referral, a PPO insurance plan could be a suitable choice for you. With a PPO plan, you have the ability to manage your own medical care without oversight from a primary care physician.
When assessing whether a PPO plan is suitable for you, the cost is a crucial factor to consider. Due to the flexibility that PPO plans to offer, the premiums are typically higher. This type of plan is beneficial for people who frequently see specialists. However, if you are looking for the most affordable health insurance plan with low out-of-pocket costs, a PPO plan may not be the best option for you.
PPO vs. HMO
HMO and PPO plans differ in the level of freedom they provide to plan members to go outside the healthcare provider’s network for coverage and care. HMO plans require staying within the network for coverage, while PPO plans offer the option to go outside the network at an additional cost. HMO plans require a primary care physician and referrals to see specialists, while PPO plans do not. HMO plans are typically less expensive than PPO plans and rely on care coordination by the network provider to control costs. PPO plans have a monthly premium and deductible but only apply to out-of-network care. Both HMO and PPO plans have similar coverage, but HMOs require prescription drugs to be filled within the network, while PPOs allow filling prescriptions anywhere for an extra cost.