Choosing between different Medicare Advantage PPO plans may seem confusing and intimidating. But it doesn’t have to be.
A Preferred Provider Organization (PPO) is a medical insurance plan that uses a network of providers (doctors, hospitals, etc.) to provide medical coverage. Unlike an HMO, with a PPO you don’t have to see your primary care physician (PCP) before you see a specialist. Additionally, you can see providers outside of the network. However, out-of-network providers may charge higher fees.
Several features make Medicare Advantage PPOs a popular choice:
As an example, 4% of Medicare eligibles in Maricopa are on PPO plans. Most carriers offer at least one plan with a $0 monthly premium.
Obviously, choosing your Medicare coverage is an important decision. You should discuss your options with a licensed advocate who can help you make the best choice.
Some things you need to consider:
Year after year, studies show that people like you are most concerned about which doctors they see. In fact, many people will sacrifice other parts of their coverage to see doctors they are comfortable with and who know their medical history.
Medicare Advantage PPO plans offer you a greater choice of providers plus the option of going outside the network. If you decide to see a provider, not in the plan’s network, you will pay more. The amount you will pay varies by plan, so make sure you are familiar with the charges for in and out-of-network providers.
Check the list of providers for each plan to see if your doctors are listed. Most doctors contract with multiple insurance plans, so you may be able to find a plan your current doctor accepts.
Remember, like any other business, providers may decide to leave a certain practice, stop accepting a certain insurance plan or retire. Therefore, it is important to choose a network that has your providers and also has a large selection of other providers in your area. Be sure to have our staff help optimize that selection.
Consider choosing doctors and facilities who are preferred cost-share or value-based providers. Insurance companies partner with these providers to help improve positive outcomes for their members and save money. Your plan may offer lower office visit copays for these providers. Our team is happy to speak with you about the different value-based providers in Arizona.
Less Desirable Network |
More Desirable Network |
|
---|---|---|
Your Doctors | Not in network | In-network & many options in case you need to switch |
Your Pharmacy | Not preferred |
Preferred |
Urgent Care |
Limited availability near you |
24/7 urgent care near you |
Hospitals |
Limited choice of hospitals |
All hospitals accepting Medicare |
Premiums vary for Medicare Advantage PPO plans, and not all insurance carriers offer these plans in Arizona. The good news is that some carriers offer a $0 premium plan in Arizona and some offer low or no copays on Primary Care Doctors.
When you compare plans, it is important to understand the difference between two key components:
Another key component of your cost is prescription drug coverage, which can vary from plan to plan. Different plans may cover drugs at different rates and tiers. Drug prices can also differ depending on which pharmacy you use to purchase your medications. But not to worry, our team is here for you to help optimize your prescription drug costs.
Another factor in what you pay for prescription drugs is the Medicare drug coverage gap. Commonly referred to as the “donut hole.”
Our team is here to walk you through the different cost tradeoffs based on your personal situation. Optimizing your coverage can lead to significant savings.
|
Higher Cost |
Lower Cost |
---|---|---|
Monthly Premium |
More than $40 |
Low or no |
Primary Care Provider |
More than $40 |
Low or no |
Specialist |
$40 – $50 |
$30 – $40 |
MOOP |
More than $6000 |
Less than $5000 |
Rx (Deductible) |
More than $150 |
$0 |
Recently, insurance carriers have included additional health-related benefits in Medicare Advantage policies. It’s easy to understand why. A healthier lifestyle reduces medical costs. The insurance provider and the insured both benefit.
Everybody wins.
Popular additional benefits included in Medicare Advantage include:
These benefits can vary widely between different plans and carriers.
Here are some considerations to take into account when evaluating a plan:
Dental coverage may include routine preventative services (twice-yearly cleaning, exam, and x-rays), comprehensive care (minor, restorative and major services), or both.
Vision and hearing coverage is usually for routine services–typically an annual exam. Materials such as hearing aids, glasses, and contacts may be partly covered as well.
Coverage of over-the-counter health products like electric toothbrushes, vitamins, medical supplies, and fitness monitors is becoming increasingly popular. This is usually a quarterly allowance which may either rollover (if not used) or be “use it or lose it.”
Gym memberships like Silver Sneakers, Silver and Fit or Renew Active may be offered. Most plans offer this at no extra cost. Check if your favorite gym is covered and if extra classes, like water aerobics and cycling classes, are covered.
Remember, these added benefits are a “win-win” for you and your insurance carrier. They save money by keeping you healthier. You get coverage and services beyond traditional Medicare and save money on things you may already pay for out of pocket.
Review these additional benefits with your Connie advocate and choose a Medicare PPO plan with the best combination of benefits for you.
Limited Benefits |
Expansive Benefits |
|
---|---|---|
Dental |
No allowance |
$500 or more for preventative |
Vision |
No allowance |
$100 or more towards glasses/contacts |
Hearing |
Medicare-covered exams cost $20 or more |
Medicare-covered exams cost $0 |
OTC |
$0 |
$50 or more every quarter |
Gym |
Don’t have a gym near you |
Has the gym you go to |
There are many factors you need to consider when choosing a Medicare Advantage PPO plan. Above we have highlighted some important factors for you to consider, however, we realize each person has their own personal needs. When you meet with our team be open about your healthcare, financial needs and preferences so can help you find the right solution for you.
Making the right decision might seem challenging given the complexity of Medicare and the choice overload. However, our local team is here to help, at no additional cost to you. It is our job to make sure whatever decision you make is stress-free and you walk away with a full understanding of your selection. Furthermore, we will continue to help you and your family throughout your healthcare journey, serving as a trusted advocate for many years to come.
Last updated: May 11, 2022
Read more by Sammy Menton
I am an Arizona Life and Health Insurance Licensed Agent and have been helping people with Medicare since 2009. I enjoy coaching youth and high school sports, watching sports, and spending time with family. I also like taking road trips and vacationing anywhere that has a beach.