What is a Medicare Advantage PPO plan?
Private insurance companies offer a Medicare PPO plan which is a type of Medicare Advantage Plan (Part C). The Preferred Provider Organization (PPO) plan has an agreement with Medicare to organize and provide benefits for you as the beneficiary. You may use the network of hospitals and doctors that are under the PPO plan and pay less. Or you can use the hospitals and doctors outside of the network and pay more
The covered benefits you will receive under a Medicare Advantage PPO plan:
| Medicare Advantage Preferred Provider Organization (PPO) plan | |
|---|---|
| Does a PPO plan cover prescription drugs? | In most cases, yes, but contact the plan to be sure. You have to enroll in a PPO plan that covers prescription drugs. |
| Will I have to choose a primary care doctor? | No. |
| Will I have to get a referral to see a specialist? | Check with your plan |
The amount you will owe for a Medicare Advantage PPO Plan
Below are the costs that you will generally pay if you enroll into a Medicare Advantage PPO Plan:
The amount you’ll pay for:
The Medicare Part B premium
- Read the following to see how you will pay the standard Part B premium. This applies to you if you are not currently receiving Railroad Retirement or Social Security benefits; your premiums are paid for by Medicare; you signed up for Part B for the first time this year; you get charged directly for your Part B premiums; and Medicaid pays for your premiums.
- If your tax return two years ago states that your adjusted modified gross income is higher than a certain amount. Then you will pay a higher Medicare Part B premium. This also applies if you did not sign up to Part B when you first eligible and owe a late enrollment penalty. However, your premium may be lower if you get Social Security benefits and enroll in Part B.
The Medicare Advantage plan monthly plan premium (if required):
Please be aware that you must pay your Part B premium even if your Medicare Advantage plan doesn’t have a premium. And a few Medicare Advantage plans have $0 premiums.
Medicare Advantage PPO plan
You will pay coinsurance, copayments, or deductibles with the PPO plan.
Note that only in emergency situations are providers obligated to treat PPO plan members. If they are non-contracted or out of your plan’s network then they do not have to treat you. Make sure to check in with us to see if we cover an out-of-network service. We recommend that you or your provider check in with us before you receive an out-of-network service. You can:
- Call our customer service number.
- Or look up your Evidence of coverage for more info. You can also see the cost-sharing that will apply to out-of-network services.