Medicare Advantage Plans: Preferred Provider Organizations (PPOs) - dummies

Medicare Advantage Plans: Preferred Provider Organizations (PPOs)

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PPOs are plans that offer managed care with fewer restrictions than HMOs. Regional PPOs cover large areas — maybe several states. Local PPOs operate within smaller areas, such as in one or several adjacent counties. In 2013, 29 percent of people enrolled in MA plans chose PPOs. These plans’ features include the following:

  • Eligibility: Like HMOs, you must have Parts A and B and live within the service area of the plan you pick. You can’t join a PPO if you have kidney failure (ESRD), but you can stay in a PPO if you develop this illness after enrollment.

  • Choice of doctors and hospitals: You can go to a doctor, hospital, or other provider outside of the plan’s network — but if you do, it’ll cost you more in higher co-pays. You don’t need a referral to see a specialist. A PPO can give you its list of network providers so you can see in advance whether your preferred doctors and hospitals accept the plan.

  • Extra benefits: Some plans offer vision, hearing, and/or dental services, though just how good this coverage is varies greatly among plans and some offer them as separate optional packages for an additional premium. Some plans offer other extras, like health club memberships.

  • Prescription drug coverage: Most PPOs include Part D drug coverage in their benefit packages, but not all do. If you join a plan that doesn’t, you can’t purchase coverage from a stand-alone Part D plan.