PPO Plans
Braden Medicare How Medicare Advantage PPO Plans Work Poster #MA PPO Plans #Medicare Advantage PPO




Preferred Provider Organization (PPO)

How PPO Plans Work

A Medicare PPO Plan is a type of Medicare Advantage Plan (Medicare Part C) offered by a private insurance company. PPO Plans have network doctors, other health care providers, and hospitals. You pay less if you use doctors, hospitals, and other health care providers that belong to the plan's network. You pay more if you use doctors, hospitals, and providers outside of the network.


Can You Get Your Health Care From Any Doctor, Other Health Care Provider, or Hospital?

In most cases, you can get your health care from any doctor, other health care provider, or hospital in PPO Plans. Each plan gives you flexibility to go to doctors, specialists, or hospitals that aren't on the plan's list, but it will usually cost more.


Are Prescription Drugs Covered?

In most cases, prescription drugs are covered in PPO Plans. Ask the plan. If you want Medicare drug coverage, you must join a PPO Plan that offers prescription drug coverage. Remember, if you join a PPO Plan that doesn't offer prescription drug coverage, you can't join a Medicare Prescription Drug Plan (Medicare Part D).


Do You Need to Choose a Primary Care Doctor?

You don't need to choose a primary care doctor in PPO Plans.


Do You Have to Get a Referral to see a Specialist?

In most cases, you don't have to get a referral to see a specialist in PPO Plans. If you use plan specialists, your costs for covered services will usually be lower than if you use non-plan specialists.


What Else do you Need to Know About This Type of Plan?

  • A PPO Plan isn't the same as Original Medicare (Medicare Part A and Part B) or a Medicare Supplement Insurance (Medigap) policy.
  • PPO Plans usually offer extra benefits than Original Medicare, but you may have to pay extra for these benefits.


How do Medicare Advantage Plans work?

Medicare Advantage Plans, sometimes called "Part C" or "MA Plans," are an “all in one” alternative to Original Medicare. They are offered by private companies approved by Medicare.  If you join a Medicare Advantage Plan, you still have Medicare.  These "bundled" plans include  Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance), and usually Medicare Prescription Drug plan (Part D).

Covered Services in Medicare Advantage Plans

Medicare Advantage Plans cover all Medicare services.  Some Medicare Advantage Plans also offer extra coverage, like vision, hearing and dental coverage.  


Rules for Medicare Advantage Plans

Medicare pays a fixed amount for your care each month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare.Each Medicare Advantage Plan can charge different out-of-pocket costs. They can also have different rules for how you get services, like:

  • Whether you need a referral to see a specialist
  • If you have to go to doctors, facilities, or suppliers that belong to the plan for non-emergency or non-urgent care
  • These rules can change each year.


Costs for Medicare Advantage Plans

What you pay in a Medicare Advantage Plan depends on several factors.


Drug Coverage in Medicare Advantage Plans

Most Medicare Advantage Plans include Prescription Drug Coverage Medicare Part D). You can join a separate Medicare Prescription Drug Plan with certain types of plans that:

  • Can’t offer drug coverage (like Medicare Medical Savings Account plans)
  • Choose not to offer drug coverage (like some Private Fee-for-Service plans)You’ll be disenrolled from your Medicare Advantage Plan and returned to Original Medicare if both of these apply:
  • You’re in a Medicare Advantage HMO or PPO.
  • You join a separate Medicare Prescription Drug Plan.


How Medicare Supplement Insurance (Medigap) Policies work with Medicare Advantage Plans

Medigap policies can't work with Medicare Advantage Plans. 


Did Anyone Mention To You That The Mayo Clinic Hospital & Barrow Neurological Hospital Do Not Accept ANY  Medicare Advantage Plans?


It is true.  And, many specialty hospitals like Cancer Treatment Centers Of America only partner with a few select Medicare Advantage Plans. Medigap policies can't work with Medicare Advantage Plans. This is why you need to read the fine print, because unfortunately, the majority of Medicare Agents are too focused on making the sale, so they intentionally side-step the truth.  If you do not ask they do not volunteer information that will make them or their plan look bad. 


In all fairness the Mayo Hospital in Rochester Minnesota accepts  all Medicare Advantage plans in Minnesota, but that is not the case in Arizona or Florida!


Disclaimer: Medicare has neither reviewed nor endorsed this information. Braden Medicare Insurance Agency is not associated with or endorsed by the United States Government or the Federal Medicare program. Braden Medicare Insurance is an Independent Medicare/Healthcare Broker offering Medicare Supplement and Medigap Plans, Medicare Advantage Plans, Medicare Prescription Drug Plans, Under 65 Health Insurance, Short Term Health Insurance, Life Insurance, Dental, Vision, and Hearing Insurance. The Braden Medicare Insurance Agency is not affiliated with the U.S. Government or the Federal Medicare Program

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