Medicare beneficiaries who enroll in a Part C, or Medicare Advantage, plan can expect to find a variety of options when it comes to how different plans manage their services and the access enrollees have to healthcare providers. A Preferred Provider Organization (PPO) plan is a type of Medicare Advantage that may give you access to the providers and coverage you need.
Understanding Common Types of Part C Insurance Plans
Private insurance carriers contract with Medicare to provide recipients with their Part A and Part B benefits alongside enhanced and expanded coverage options. The coverage these plans provide that goes above and beyond what Original Medicare offers can be structured through the following categories of insurance programs:
Preferred Provider Organization (PPO)
As the name suggests, a PPO offers coverage through a network of chosen providers. Enrollees who use the services offered by these providers can expect to pay fewer out-of-pocket expenses than if they see providers who are outside of the insurer’s network. Each carrier determines their own policies regarding how much this difference may be, but it can mean an enrollee pays a higher percentage or the entire cost of any services received from out-of-network providers. If you belong to a PPO, you usually do not need to get a referral before seeing a specialist.
Health Maintenance Organization (HMO)
An HMO covers care received by providers within its network — which means that seeing providers outside of that network can mean a recipient is faced with paying the entire cost of the care they received. Exceptions to this generally include emergency care services or medically necessary treatments like dialysis. Special rules may apply to those exceptions, such as there being no in-network option within a certain number of miles from the recipient’s home. Some HMOs do have point-of-service options that have fewer restrictions on out-of-network service providers. When you join an HMO, you usually have to choose a primary care physician who will manage your care. You’ll need to see your primary care physician for a referral before seeing a specialist.
Private Fee-for-Service (PFFS)
Much like PPOs and HMOs, some PFFS plans may use a network-based structure to control the cost of care for both the carrier and the recipient. This isn’t as standard as it is for the other plan types, but it’s an important consideration to explore when evaluating your options for Medicare coverage. Notably, PFFS plans do not usually require recipients to acquire a referral from a primary care physician before they see a specialist for care.
Special Needs Plans (SNPs)
Medicare recipients with qualifying medical conditions or circumstances can enroll in an SNP, which operates similarly to a PPO in that it uses a network of approved providers in order to control the overall cost of care for its enrollees. For recipients with chronic or terminal health issues, this means they have access to a cost-controlled and targeted network of providers that is specifically designed to meet their needs.
Why Medicare Recipients Choose a PPO
Many Medicare recipients are familiar with the structure of a PPO given its popularity in the private insurance marketplace. Those who find their current doctor remains available under a Part C PPO plan can expect to transition easily; if your doctor is not in a PPO’s network, check the cost of out-of-network care to gauge whether or not other plan benefits outweigh the increase in your cost-sharing obligations.
Medicare recipients should also note that a standalone Medicare Part D prescription drug plan cannot be purchased while you are enrolled in a Part C PPO plan. If you’re interested in prescription drug coverage, be sure to choose a PPO plan that includes prescription drug coverage. If you have coverage for prescription medication through a non-Medicare plan, you may be able to enroll in a Part C PPO plan that does not have Part D coverage included with it.
Enrollees of a Medicare Advantage PPO plan are not required to choose a primary care physician or acquire a referral for most in-network specialist services. However, both Original Medicare and a PPO carrier may require documentation that certain treatments and services are medically necessary before approving coverage for those treatments and services.