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What Is a Medicare Advantage PPO Plan?

Medicare PPO stands for Preferred Provider Organization. A PPO means the insurance provider has a network of preferred health providers who offer negotiated service rates for your health care. A PPO plan is a type of Medicare Advantage plan, so you can enroll in this type of plan as an alternative to Original Medicare. Like other types of Medicare Advantage plans, you need to be enrolled in Medicare Part A and Medicare Part B, and you also need to live in the plan’s service area.

If you’re interested in finding out more information about Medicare Advantage PPO plans, get in touch with one of our experienced local Medicare agents. We specialize in helping people all over North Carolina with their health insurance to get the best coverage for you. 

HealthPlans of NC

Health Plans of NC, Kelly Quinn

Benefits of a Medicare Advantage PPO

There are some benefits of enrolling in a Medicare Advantage PPO plan, including:

Lower copays

If you’re enrolled in a Medicare Advantage PPO, you will typically pay lower copays when visiting service providers who are part of the preferred network of your insurer. You rarely need to select a primary care physician or require a referral to ‌visit a specialist for your health needs. Every plan has different rules and network providers, so it’s essential to examine your plan before enrolling to ensure it offers everything you need. Our Medicare agents can help if you need any guidance. 

Out-of-pocket maximum 

All Medicare Advantage PPO plans have to set an annual limit on your out-of-pocket costs. This limit is called your maximum out-of-pocket (MOOP). Setting this limit can help protect you from high medical expenses if you need to pay for expensive treatments or require extensive care. Once you reach your limit, you won’t owe any cost-sharing for any services under Medicare Part A or Medicare Part B for the rest of the year. Depending on your plan, this can also apply to additional benefits, including dental, vision, or hearing.

The out-of-pocket costs that contribute to your MOOP include coinsurance, deductibles, and copayments for Medicare Part A and Part B covered services, as long as you use in-network providers. In 2022, the MOOP is $7,550. However, be aware that some plans may set lower limits. For example, if you’re in a PPO plan that covers you for services received from out-of-network providers, your plan will typically have one limit for in-network costs and another limit for in-network and out-of-network costs combined.

Key features of a Medicare PPO plan

Here are some of the key features of a Medicare Advantage PPO plan: 

  • You can choose to visit out-of-network doctors, but you pay a higher cost.

  • Premiums can be lower than a Medicare supplement plan because you agree to specific rules and restrictions of the plan.

  • A PPO plan typically includes Medicare Part D prescription drug coverage. Be aware that you can’t select a different Part D drug plan with a PPO. If you need prescription drug coverage, it has to be part of your Medicare Advantage PPO plan. 

  • Some plans include additional benefits, for example, dental, vision, or even discounts on gym memberships. Some limitations and copayments can apply. 

  • Medicare PPO plans are subject to annual changes, including changes to pharmacy networks, provider networks, benefit formulary, premiums, or copayments. These changes come into effect on January 1 every year, so it’s important to review plan changes during the Annual Enrollment Period to decide if your coverage is still right for you. 

Costs of Medicare PPO plans

When you enroll in a Medicare PPO plan, it’s essential to review your summary of benefits, which outlines what your coverage includes and details of any copays and deductibles. If you need help to review your options, our North Carolina agents can help.

When reviewing your benefit summary, it’s important to be aware of the following common expenses:

  • You’re required to pay a monthly premium for your PPO plan. Some plans can have a $0 premium, but it depends on the plan and its inclusions. Your premium may also change each year. 

  • You’ll still be required to pay for Medicare Part B. In 2022, this cost is $170.10 per month, although this amount varies depending on how much you earn. 

  • You must pay copays each time you see a health provider or use a specific service. 

  • When seeing an out-of-network provider, the costs can be higher, and you may also need to pay an up-front deductible. 

Medicare PPO vs. Medigap

Whether a Medicare Advantage PPO plan or a Medicare supplement plan is better for your needs depends on your personal preferences. 

A medical supplement plan, known as Medigap, helps cover the gap of anything not covered by Medicare Part A or Part B. Typically, you end up with very low or no out-of-pocket costs for your health care. For example, you won’t even have to pay a copay when visiting your doctor. Medigap plans can be more expensive than Medicare PPO plans, but if you have high health care needs, they can save you in the long term.

A Medicare PPO plan typically has lower premiums than a Medigap plan. It does limit you to seeing a specific network of doctors to get the best copays. You’ll need to pay copays each time you use a service, including doctor visits, surgeries, lab work, hospital stays, and medical equipment. While you have lower premiums, you’ll need to consider how often you’re likely to access these services to determine what’s best for your needs. At Health Plans of NC, we can offer guidance and support to select the right plan for you.

Need help working out the right plan?

Researching PPO Medicare plans can be overwhelming. Our licensed and experienced Medicare agents NC specialize in advising about North Carolina Medicare plans. In addition, we offer independent advice to help you get the best coverage for your needs. Get in touch with us today to find out more or compare plans online. 

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