3 Reasons Why Medicare Advantage PPO Plans Are a Good Choice

Jul 27, 2023

3 Reasons Why Medicare Advantage PPO Plans Are a Good Choice

Medical provider promoting Medicare Advantage Plans


Key Takeaways

  • PPO Plans equal more flexibility
  • Yes Medicare Advantage PPO Plans can allow you to see any doctor who accepts Medicare
  • Not All PPO plans are created equal


What is A Medicare Advantage PPO Plan


PPO stands for preferred provider organization and a Medicare Advantage Plan PPO is another way to receive your Medicare benefits through a private insurance carrier. All Medicare Advantage Plans must cover all Medicare Part A&B benefits and the coverage has to be as good or better than original Medicare. On top of that all Medicare Advantage Plans also known as Part C must have a maximum out of pocket limit. This is huge because it puts a cap on how much you can come out of pocket during a calendar year. Original Medicare itself does not have this in place which can lead to massive out of pocket bills when serious health conditions or surgeries occur.

In 2023 Kaiser Family Foundation reported that the percentage of PPO plans grew from 30% to 40% in 2019. For years HMO style plans were far more dominant than PPO plans. This growth can be attributed to the consumers desire to have more choices and flexibility when choosing medical providers and hospitals. PPO plans have a preferred list of in network providers where consumers will receive lower copays and out of pocket cost sharing but they do allow you to see out of network providers usually at a higher out of pocket cost. This flexibility is attractive to a lot of consumers who want to have more options in case they need them.


3 Reasons Why Consumers Choose PPO Medicare Advantage Plans 


  1. **Greater Flexibility in Provider Choice**: One significant advantage of Medicare Advantage PPO plans over HMO plans is the flexibility in choosing healthcare providers. PPO plans typically allow beneficiaries to see both in-network and out-of-network providers, while HMO plans usually restrict coverage to in-network providers only. This means that with a PPO plan, consumers can continue seeing their preferred doctors or healthcare specialists even if they are not part of the plan’s network. This can be particularly appealing to individuals who have established relationships with certain healthcare providers and wish to maintain continuity of care.


  1. **Less Need for Referrals**: HMO plans often require beneficiaries to select a primary care physician (PCP) and obtain referrals from that PCP before seeing specialists or receiving certain medical services. In contrast, Medicare Advantage PPO plans typically do not require referrals to see specialists. This streamlined access to specialists can be attractive to consumers who want more control over their healthcare decisions and prefer not to go through the process of getting referrals for specialized care.


  1. **Out-of-Network Coverage**: While both PPO and HMO plans provide coverage for in-network services, PPO plans generally offer some level of coverage for out-of-network care as well. Although the out-of-network benefits may not be as comprehensive as in-network coverage, it can still provide a safety net for unexpected healthcare needs, especially when traveling or in areas with limited network options. This out-of-network coverage can be an important factor for consumers who value the added security and peace of mind it offers.


However, it’s essential for consumers to carefully review the specifics of each Medicare Advantage plan, including costs, coverage, and the network of providers, before making a decision. The suitability of a plan can depend on individual healthcare needs, budget, and preferred level of freedom in choosing healthcare providers. Changes or updates to Medicare regulations and plans may have occurred since my last update, so it’s always a good idea to consult with a licensed insurance agent or a Medicare counselor to get the most current and accurate information.


 Buyer Beware All PPO Plans Are Not Created Equal


It’s true Medicare PPO plans are growing in popularity and the insurance carriers are paying attention to this trend and offering more PPO Plan options. Just like any other product not all PPO Plans are created equal. Since it typically costs insurance carriers more money to offer PPO plans many carriers offer several options and some of them just are not what you think you are getting. 


Example: XYZ company in my area offers a PPO plan that has $a monthly premium and even gives money back into your social security check each month  just for enrolling in their plan. This plan also has a small vision benefit, dental benefit and free gym membership included. Sounds great, right sign me up! What if I told you the plan has one of the smallest network provider networks around and it also has a cost sharing of 40% coinsurance when you use out of network providers. The dental coverage they advertise is only $500 per year and the vision benefit is $75 towards a pair of glasses. Many PPO Plans are misleading with their advertising of their benefits and none of them will mention that they created a restricted network for their plan.  When you see an out of network doctor with a PPO a couple of things could happen, one the doctor’s office will take your insurance and bill it and you will pay your cost share just like if it was in network. The next thing that happens a lot these days is the doctor’s office says we don’t accept that insurance. That leaves you responsible for the full bill amount and if you want to get reimbursed then you need to submit your claim to the insurance carrier and wait for a portion of the claim to get sent to you.


Bottom Line


Medicare Advantage Plans are necessary and very helpful to many consumers on Medicare. Medicare Supplement Plans can be pricey and their rates consistently rise year after year. As we get older let’s face it most of us are not making more money and every dollar counts. Medicare Advantage Plans provide a nice alternative to original Medicare and PPO Plans have definitely grown in popularity. Even though not all PPO plans have large provider networks, most do provide larger networks than traditional HMOs and they never require referrals to see a specialist. When shopping for Medicare Advantage Plans it is always important to do your research to make sure you have the best plans for your needs. Plans do vary greatly by area and they are not always easy to compare, if you need help with comparing Medicare insurance options you should contact an Independent agent or agency like The Modern Medicare Agency who offers free Medicare consultations and can help compare several options side by side.