What Is a PPO?
A PPO plan allows you to balance your preferences with your budget. For example, most PPOs let you choose any doctor or hospital that accepts Medicare, but you pay less for the services you get from in-network providers.
This element of freedom and choice is what many beneficiaries like about PPOs — because you don’t have as much flexibility with HMOs. That’s the main difference between the two types of plans.
What Else You Should Know
- Most PPOs include prescription drug coverage.
- Unlike HMOs, PPOs usually DON’T require you to choose a primary care doctor, nor do they require a referral to see a specialist.
- Copayments for doctor visits and routine physicals are affordable.
Is a PPO Plan Right for You?
PPO may be the best option depending on your health and financial situation. Before you decide, just know you’ll usually have higher monthly premiums with a PPO than you would with an HMO. That’s the tradeoff for receiving some coverage outside of your plan’s network.
PPOs can vary in terms of costs. Some are designed with copayments only. You may have a deductible with coinsurance, which means you’ll pay a certain percentage until you meet that deductible.
Here’s the bottom line. If the option of a less restrictive network for health care appeals to you, you should look into PPOs.
Who Qualifies for a PPO Plan
To be eligible for a Medicare Advantage plan, you must be enrolled in both Parts A and B, and live in the plan’s service area.
Do You Need to File a Claim?
Sometimes, you have to pay out-of-network providers for services before you file a claim for reimbursement from your insurance company.
What If You Need to Fill a Prescription?
PPOs allow you to fill a prescription nearly anywhere. However, you might pay more for prescription drugs if you use an out-of-network pharmacy.
When Can You Apply?
There are four main enrollment periods during which you can join a PPO plan:
- Your Initial Enrollment Period (IEP)
- General Enrollment Period (GEP)
- Annual Enrollment Period (AEP)
- Medicare Advantage Open Enrollment (OEP).
Your IEP falls is a seven-month period, beginning three months before and ending three months after the month you turn 65. The GEP and OEP go from January 1 to March 31. Medicare’s AEP is from October 15 to December 7. These periods allow someone to enroll, change, or leave an Advantage plan.