What is a preferred provider organization?

Preferred Provider Organization (PPO) health insurance is a type of Medicare Advantage plan. PPO plans give beneficiaries access to a network of medical providers who have contracts with the insurance company at lower rates. As an added benefit, subscribers can still see health care providers out of network while still getting coverage.

In addition, PPOs are private insurance companies that are paid by the federal government in order to provide the benefits of Medicare. Because PPOs are supported by the government, they can provide benefits at a reduced cost.

Legally, PPO plans must provide the same benefits as Original Medicare. However, PPOs have different rules for their coverage than other Advantage plans. In general, the premiums for PPO plans are higher than HMO premiums, but allow subscribers more options.

What do I need to know about preferred provider organization coverage?

Preferred Provider Organization Benefits

Preferred Provider Organization Benefits

The main advantage of PPO coverage is the greater freedom and flexibility of the plan. When you join a PPO plan, you do not have to select a primary provider as you do with other health insurance plans. This means you can see any provider within the network and still receive coverage.

HMO vs PPO Insurance

The main difference between HMO and PPO plans is the adaptability of the plan. As we mentioned, PPO plans do not require that you select a primary care provider (PCP). In contrast, HMO plans do require a PCP. 

HMO plans typically focus on helping you maintain your health while reducing out-of-pocket costs. PPO plans, on the other hand, offer wider areas of coverage and reduce the requirements and costs associated with seeing a specialist.

In terms of costs, PPO plans usually cover their costs by establishing copayments, or copays. When your plan has a copay, you will be charged a small fee to help pay for your care. Usually, PPO copays are set in fixed amounts. However, keep in mind that there are additional premiums you must pay on top of your Medicare Part B premiums.

HMO plans usually have lower costs overall, especially if you are in good health. However, if you receive care out of network, you will have to pay out of pocket.

In summary, PPO plans are usually more expensive than HMO plans but offer more convenient and accessible coverage.

Preferred Provider Organization Insurance can offer greater freedom than other coverage plans
preferred provider organization plans may cost more than other plans

Preferred Provider Organization Care Costs

The biggest disadvantage of a PPO plan compared to other Advantage plans is the cost. Because these types of plans are more convenient than HMO plans, they are more expensive. You should also know that some PPO plans can offer Part D prescription drug coverage, but also at an additional cost.

Another cost of PPO plans comes from deductibles, which are included in most PPO plans. In order for your plan to begin paying for coverage, you will have to pay out of pocket until you reach the deductible amount.

Alternatively, there are some plan options that allow you to mitigate some of the higher costs. If you choose a plan with a copay option, it can reduce the costs of your premiums. Companies choose to lower premiums for copay plans because copays discourage people from seeking unnecessary medical services.

Finally, if you should know that if you receive out of network coverage at a high cost, your PPO coverage may not apply.

Eligibility for PPO Plans

In order to qualify for a PPO plan, you must have both Medicare Parts A and B. Also, you cannot be enrolled in another Medicare Advantage plan, but if you need Part D coverage, it can be added to your plan. 

Usually, you cannot join a PPO if you have End-Stage Renal Disease. However, if you develop ESRD after joining a PPO, you may be able to retain PPO coverage. Alternatively, you can join a Special Needs Plan (SNP) health plan or a PPO that provides ESRD coverage.

Let Us Help You Find The Right Plan

At Buffalo Health Advisors, we believe in providing solutions to individuals as they transition to Medicare plans. Not only can Medicare Advantage plans work to protect your health, choosing the right plan can go a long way toward protecting your wealth. Buying one of these plans is critical if you plan to live off of fixed income during your retirement years.

Learn more about your available options at no cost to you! We know that looking for health insurance plans can be confusing and stressful. Call or stop by our Nashville, TN office and you can find someone to talk to and make the process easier. Any of our experienced health insurance agents can help you find the perfect Medicare Advantage plan for you.

For more information about how working with an agent can help you, visit our In the Media page where our agents answer some frequently asked questions.

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