Medicare Preferred Provider Organizations (PPOs) must provide you with the same benefits as Original Medicare but may do so with different rules, restrictions, and costs. PPOs can also offer additional benefits. Below is a list of general cost and coverage rules for Medicare PPOs. Remember to speak to a plan representative to learn the details about any plan you are considering.
Costs
- Many plans charge a monthly in addition to the Part B Part B, also known as medical insurance, is the part of Medicare that covers most medically necessary doctors’ services, preventive care, hospital outpatient care, durable medical equipment (DME), laboratory tests, x-rays, mental health services, and some home health care and ambulance services. premium. Plans may charge a higher premium if you also have Part D coverage.
- Plans may set their own deductibles, copayments, and other cost-sharing Cost-sharing is the portion of medical care costs that you pay yourself, such as a copayment, coinsurance, or deductible, if you have health insurance coverage. See also: Out-of-Pocket Costs. for services. PPOs typically set fixed copays for in-network services and may charge more if you see an out-of-network Out-of-network means not part of a private health plan’s network of health care providers. If you use doctors, hospitals, or pharmacies that are not in your Medicare Advantage Plan or Part D plan’s network, you will likely have to pay the full cost out of pocket for the services you received. provider.
- PPOs set two annual limits on your
out-of-pocket costs
Out-of-pocket costs are health care costs that you must pay because Medicare or other health insurance does not cover them.
. One limit is for
in-network
In-network means part of a private health plan’s network of providers. If you use doctors, hospitals, pharmacies, home health agencies, skilled nursing facilities, and durable medical equipment suppliers that are in your Medicare Advantage Plan or Part D plan’s network, you will generally pay less than if you go to out-of-network providers.
costs and the other is for combined in-network and
out-of-network
Out-of-network means not part of a private health plan’s network of health care providers. If you use doctors, hospitals, or pharmacies that are not in your Medicare Advantage Plan or Part D plan’s network, you will likely have to pay the full cost out of pocket for the services you received.
costs. These limits may protect you from excessive costs if you need a lot of care or expensive treatments.
- For example, your PPO may have an out-of-pocket limit See Maximum Out-of-Pocket (MOOP). of $1,000 for your in-network costs, and an out-of-pocket limit of $4,000 for your combined in-network and out-of-network costs. You could reach the combined limit by spending $1,000 on in-network services and $3,000 on out-of-network services, or by spending $4,000 on out-of-network services.
Providers
- You are not required to select a primary care provider (PCP) The primary care provider (PCP) is the doctor or other health care worker who manages your health care and gives you a referral to consult a specialist if you need it. In Medicare Advantage, many Health Maintenance Organizations (HMOs) require you to select a PCP and get their permission or referral before seeing a specialist. Preferred Provider Organizations (PPOs) and Private Fee-for-Service (PFFS) plans do not have this requirement. .
- You can see a specialist A specialist is a doctor who specializes in treating only a certain part of the body or a certain condition. For instance, a cardiologist only treats people with heart problems. without a referral Referrals are authorizations that Medicare Advantage Plans usually require for services not provided by your primary care provider (PCP). For example, Health Maintenance Organizations (HMOs) generally require you to get a referral from your PCP in order to see a specialist or get an eye exam. .
- PPOs cover your care if you visit an out-of-network provider or facility. However, you may pay a higher amount for out-of-network services.
- PPOs cannot charge more than Original Medicare Original Medicare, also known as Traditional Medicare, is the fee-for-service health insurance program offered through the federal government, which pays providers directly for the services you receive. Almost all doctors and hospitals in the U.S. accept Original Medicare. charges for certain kinds of care, including chemotherapy, dialysis Dialysis is the treatment used to artificially cleanse your blood of toxins when your kidneys no longer work. , and skilled nursing facility (SNF) Skilled nursing facilities (SNFs) are Medicare-approved facilities that provide short-term post-hospital extended care services. care. However, PPOs can charge higher copays for other services, including home health, durable medical equipment (DME) Durable medical equipment (DME), also known as DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies) is equipment that primarily serves a medical purpose, is able to withstand repeated use, and is appropriate for use in the home; for example, wheelchairs, oxygen equipment, and hospital beds. Medicare only covers DME if your provider says it is medically necessary for use in the home. , and inpatient An inpatient is a patient who has been formally admitted into the hospital by a doctor. Most inpatient care is covered under Medicare Part A (hospital insurance). hospital care.
Benefits
- Your PPO may offer additional benefits, such as vision, hearing, and/or dental care. Check with the plan directly to learn about coverage rules and restrictions for any added benefits.