Medicare Medicare is the federal government health insurance program that provides health care coverage if you are 65 or older, are under 65 and receive Social Security Disability Insurance (SSDI) for 24 months, begin receiving SSDI due to ALS/Lou Gehrig’s Disease, or have End-Stage Renal Disease (ESRD) no matter your age. You can receive health coverage directly through the federal government (see Original Medicare) or through a private company (see Medicare Advantage). Preferred Provider Organization (PPO) A Preferred Provider Organization (PPO) is a type of private insurance plan. Some Medicare Advantage Plans are PPOs. People enrolled in a PPO can see any provider, but you generally pay more when seeing out-of-network providers. See also: Medicare Advantage. are private companies that the federal government pays to administer Medicare benefits. Like all Medicare Advantage Plans, PPOs must provide you with the same benefits, rights, and protections as 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. , but they may do so with different rules, restrictions, and costs. Some PPOs offer additional benefits, such as vision and hearing care.
Eligibility and costs basics
You must have both Parts A and B to join, and generally you will continue paying your Medicare 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. . Your PPO may also charge an additional premium, on top of the Part B premium. If you want Part D coverage, you will receive it through your PPO. Plans may charge a higher premium if you also have drug coverage.
Note: If you join a Medicare Advantage Medicare Advantage, also known as Part C, Medicare Private Health Plan, or Medicare Managed Care Plan, allows you to get Medicare coverage from a private health plan that contracts with the federal government. All Medicare Advantage Plans must offer at least the same benefits as Original Medicare (Part A and Part B), but can do so with different rules, costs, and coverage restrictions. Plans typically offer Part D drug coverage as part of Medicare Advantage benefits. Medicare Advantage Plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS) plans, Special Needs Plans (SNPs), and Medicare Medical Savings Accounts (MSAs). Plan and you want Part D Part D, also known as the Medicare prescription drug benefit, is the part of Medicare that provides prescription drug coverage. Part D is offered through private companies either as a stand-alone plan, for those enrolled in Original Medicare, or as a set of benefits included with a Medicare Advantage Plan. coverage, you must receive coverage from your plan. You cannot enroll in stand-alone Part D coverage unless you join a Medical Savings Account (MSA) or Private Fee-for-Service (PFFS) plan that does not offer prescription drug coverage.
Benefits access basics
Once you have joined a PPO, you should receive a benefit card from your plan. You will use your PPO benefit card instead of your Medicare card Everyone who enrolls in Medicare receives a red, white, and blue Medicare card. It lists your name and the dates that your Original Medicare hospital insurance (Part A) and medical insurance (Part B) began. It also shows your Medicare number, which serves as an identification number in the Medicare system. If you get Medicare through the Railroad Retirement Board, your card will say “Railroad Retirement Board” at the bottom. If you are enrolled in a Medicare Advantage Plan, you will also have a card from that plan (see Medicare Advantage Plan Card). when you go to the doctor or hospital.
After enrolling in a PPO you can see any provider, but you generally pay more when seeing 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. providers. PPO plans typically offer fixed copayments when you use the plan’s network A network is a group of doctors, hospitals, and pharmacies that contract with a Medicare Advantage Plan to provide health care services. Generally, plan members will have the lowest costs when using providers and facilities in the plan’s network. Networks may be made up of both preferred and non-preferred providers. .
There are two types of Medicare PPO plan:
- Regional PPOs, which serve a single state or multi-state areas determined by Medicare
- Local PPOs, which serve a single county or group of counties chosen by the plan and approved by Medicare
Both types of PPO must have a maximum Out-of-Pocket Limit See Maximum Out-of-Pocket (MOOP). for all of your in-network care and a combined in-network and out-of-network care limit.
Medicare PPOs are not available everywhere. Call 1-800-MEDICARE or your State Health Insurance Assistance Program (SHIP) to find out if there is a PPO available in your area. To enroll in a PPO, call Medicare or the plan directly. Be sure to make an informed decision by contacting a plan representative to ask questions before enrolling.