What Is a Medicare PPO Plan?

Medicare Advantage plans are private health insurance plans available to seniors who qualify for Medicare. These plans cover Parts A and B of Medicare insurance and typically also include prescription drug coverage and other services such as hearing and dental that Original Medicare does not cover. Medicare Preferred Provider Organization (PPO) Plans are one of four common kinds of Medicare Advantage plans. The other three common types are:

  • Medicare Health Maintenance Organization (HMO) Plans

  • Special Needs Plans (SNP)

  • Private Fee-for-Service (PFFS) Plans

A Medicare agent at PBC can help you learn about whether a Medicare PPO plan is right for you. In this article we’re going to take an overall look at Medicare PPOs and how they work.


How Medicare PPOs work


PPOs have the same requirements as other Medicare Advantage plans; they must provide seniors with the same benefits, rights, and protections as Original Medicare. Most PPOs offer extra benefits, such as vision and hearing care but these services may cost extra.


PPO Plans have network health care providers and hospitals nationwide, making them a good option for kupuna who visit their family on the mainland or travel regularly (in normal times). Members do pay less if they seek care from in-network doctors and hospitals and pay more if they use doctors, hospitals, and providers outside of the network. Check with a Medicare Agent for individual plan details.


Can I join a Medicare PPO?


In order to qualify for a Medicare PPO Plan, you must already be enrolled in Medicare Parts A and B. In most cases, you will continue paying your Medicare Part B premium. Some PPOs charge an additional premium, on top of your Part B premium. One reason that a plan would charge an additional premium is if it includes prescription drug coverage and other additional services.


On a Medicare PPO do I have to get care within the PPO network?


It’s important to know whether you would need to receive health care from within the PPO network or whether you would have the freedom to choose your health care provider and hospital. Because there are preferred providers in a Medicare PPO, it is more cost efficient to receive in-network care but it is not a requirement.


Do I need to have a primary care physician if I choose a Medicare PPO?


PPOs do not require their members to choose a Primary Care Physician (PCP).


Will I need to get a referral to see a specialist?


In general, PPOs do not require their members to get a referral before seeing a specialist but it will cost less if the patient chooses an in-network specialist.


Will I get prescription drug coverage on a Medicare PPO?


Most PPO Plans do cover prescription drugs but you will want to speak with your Medicare Agent to confirm that you are choosing a PPO with Medicare drug coverage (Part D) if you require it. This is because you cannot purchase Medicare Part D as a standalone plan when you have a PPO.


Contact a PBC Agent for Help


Our independent insurance agents are dedicated to assisting people on Medicare and those who are ready to transition from employer coverage to personal retirement coverage. We help kupuna understand their benefits options and apply for additional coverage, as needed. Because we represent all the major Medicare Advantage and supplement plans in Hawaii, we are able to offer unbiased advice; all at no cost to our clients.


At PBC, our clients are our number one priority and we look forward to getting to know you and your needs. Call us today at (808) 738-4500 to see how we may be of assistance.


email: info@pbchawaii.com

office: 808.738.4500

1221 Kapiolani Blvd PH30

Honolulu, HI 96814

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