What You Should Know About Medicare Advantage PPO Plans

Updated for January, 2022

Key Takeaways:
  • A Medicare Advantage PPO plan covers more than basic Medicare. Medicare Parts A and B take care of many basic health needs, but they don’t cover everything.
  • When staying within your Medicare Advantage PPO network, you will pay less for healthcare services than if you use doctors, hospitals, or providers outside the network.
  • If you want Medicare drug coverage, you must join a Medicare Advantage PPO plan that offers it. If you join a PPO plan that doesn’t offer prescription drug coverage, you won’t be eligible for a Part D plan.
  • It’s best to sign up for a Medicare Advantage PPO plan during the annual Open Enrollment Period. Your plan won’t need to be underwritten, and you can get the same price as people who are in good health.
  • Medicare Advantage PPOs include Medicare Special Needs Plans (SNPs) that serve seniors with chronic or disabling conditions.

A Medicare Advantage Preferred Provider Organization (PPO) provides and coordinates healthcare benefits for you through Medicare. These benefits are provided via private insurance companies that contract with Medicare.

A Medicare Advantage PPO has its own network of doctors, hospitals, and medical facilities for you to choose among. To select the best plan for you, there are certain things you need to know.

What is a Medicare Advantage PPO Plan?

A Medicare Advantage PPO Plan is an alternate way to receive your Medicare Part A (hospital insurance) and Part B (medical insurance) benefits. Medicare Parts A and B (also known as Original Medicare) cover many basic health needs, but they do not cover everything many seniors need. In contrast, a Medicare Advantage PPO plan covers much more than Original Medicare.

A Medicare Advantage PPO plan is often less expensive than the same coverage you would get if you used Original Medicare.

Why Should You Choose a Medicare Advantage PPO Plan?

With a Medicare Advantage PPO plan, you can select from a network of doctors, hospitals, and other healthcare providers. When staying within your network, you’ll pay less for healthcare services than if you use doctors, hospitals, or providers outside the network./p>

Who is Eligible for Medicare Advantage PPO Plans?

In order to be eligible, you must be enrolled in both Medicare Part A and B. Some states require that you are age 65 or older, even if you are eligible to enroll in Medicare at an earlier age.

What Do Medicare Advantage PPO Plans Cover?

These plans provide the same level of coverage as Medicare Part A and Part B, and more. A Medicare Advantage PPO plan might also cover things like:

  • Dental care
  • Prescription drugs*
  • Hearing aids
  • Vision care and eyewear
  • Fitness plans and gym memberships
  • Access to 24-hour Nurse Helplines

*If you want Medicare drug coverage, you must join a PPO plan that offers it. If you join a Medicare Advantage PPO plan that doesn’t offer prescription drug coverage, you won’t be eligible to sign up for a Medicare prescription drug plan (Part D).

In most instances, you can use your Medicare Advantage PPO plan with doctors or hospitals in your area. But, if your doctor, specialist, or hospital isn’t included on your plan, you’ll have to pay more. This is why it is important to verify that your preferred healthcare providers and hospital are included in your plan.

What Are Some of the Cost Considerations When Using a Medicare Advantage PPO Plan?

A Medicare Advantage PPO plan is often less expensive than the same coverage you would get if you used Original Medicare.

Medicare Advantage PPO plan costs vary. Premiums are based on your location and your community’s demographics, the plan’s rating, and which insurance company is offering the plan.It’s important to research and compare the available plans to find one that works for you.

Every year, Medicare Advantage PPO plan providers set the amounts they charge for premiums, deductibles, and services. These insurers (not Medicare) decide how much you pay for your covered services. However, what you pay for your Advantage PPO plan may only change only once a year, on January 1.

What About Special Needs Plans?

Medicare Advantage PPOs include Medicare Special Needs Plans (SNPs). These are a type of Medicare Advantage plan that serves seniors with chronic or disabling conditions. These plans require that you obtain healthcare from doctors and hospitals in their approved Medicare SNP networks. SNP networks vary in size, as well as in the different populations they serve.

To be eligible for a Special Needs Plan, you must fit into one of the following groups:

  • You live in certain institutions (like nursing homes), or you require nursing care at home.
  • You’re eligible for both Medicare and Medicaid.
  • You have specific chronic or disabling conditions (such as diabetes, end-stage renal disease, HIV/AIDS, chronic heart failure, or dementia).

Note: Medicare Advantage PPO plans may limit membership beyond these groups.

If you already have a Medicare Advantage PPO plan, but you’re not happy with it, you can change plans during the Medicare Open Enrollment Period.

How Do You Sign Up for a Medicare Advantage PPO Plan?

In order to receive the benefits a Medicare Advantage PPO plan provides, you will contract with a private insurance company like United Healthcare, Blue Cross Blue Shield, AARP, or others.

It’s best if you sign up during the annual Medicare Open Enrollment Period. Medicare’s Open Enrollment Period is October 15 through December 7 each year.

This is an important time window to remember because private insurance companies are typically allowed to perform medical underwriting to decide whether to accept your application and how much to charge you.

If you try to apply for a Medicare Advantage PPO plan outside the Open Enrollment Period, and you don’t meet the plan’s medical underwriting requirements, there’s no guarantee that an insurance company will sell you a policy. However, during the Open Enrollment Period, you can buy any Medicare Advantage PPO plan a company sells for the same price, regardless of your current health.

If you already have a Medicare Advantage PPO plan, but you’re not happy with it, you can also change plans during the Medicare Open Enrollment Period.

To find more Medicare Advantage PPO plan information or to compare plans, call 1-800-MEDICARE. You can also go online.