Finding the right Medicare plan can be a bit overwhelming. It is easy to get confused when reading about the many options available. At Alignment Health Plan we’re here to help you navigate the marketplace and find the best plan for your family, so you can get great coverage without the stress.

 

What is a Medicare Advantage PPO Plan?

There are several types of Medicare Advantage plans available, but most Medicare Advantage plans fall into two categories: HMO and PPO. Health maintenance organization plans, or HMOs, require you to select a primary care provider who coordinates most, if not all, of your care. Preferred provider organization plans, on the other hand, allow members to select their preferred healthcare organizations and professionals without primary care physician oversight.

 

How Do Medicare Advantage PPO Plans Work

As you might have guessed, preferred provider organization plans allow you to see whatever provider you prefer for care. You can switch PCPs, healthcare systems, or specialists without getting approval. Members are also free to visit a provider who is out of network. In-network providers offer lower rates and more coverage. However, there is generally still some coverage offered for out-of-network services or providers on a PPO network - unlike an HMO which typically only covers in-network providers and services.

 

What Do Medicare Advantage PPO Plans Cover

Unlike an HMO plan that usually only covers in-network providers and services, PPO plans generally offer at least partial coverage for out-of-network costs. This means you can see a specialist outside your provider network, receive a treatment that your plan doesn't cover, or get prescription drug coverage that isn't in network. While you will usually have to pay a larger copay, coinsurance, or deductible amount, you can still receive discounts on services you choose. An HMO plan, on the other hand, will almost always deny any coverage for out-of-network costs outside of some emergency services, so that’s something to keep in mind when making your decision.

 

Is A Medicare PPO Right For You?

Many people struggle to decide between a Medicare Advantage PPO and an HMO plan. In general, HMOs are preferred by patients who have a dedicated in-network primary care doctor they want to continue seeing. Patients who do not have serious health issues and don't often need to see specialists or anticipate any out-of-network procedures could benefit from an HMO plan.

On the other hand, anyone who does not want to be tied to one dedicated PPC who coordinates and helps determine all care should consider a medicare PPO plan. PPO plans offer more freedom and flexibility for patients. Those who have chronic health issues often opt for PPO plans. However, anyone who regularly needs to see specialists, receive non-covered services, or take specialty medication could greatly benefit from the freedom provided by PPO coverage.

 

Advantages of Medicare PPOs

• Freedom - The big advantage of PPO networks is the freedom to choose your own providers and healthcare options. On this plan, you won’t have to wait on your primary doctor to coordinate care before seeking a second option or scheduling a new appointment.
• Flexibility - If you anticipate a move or have complex health issues that require seeing new physicians regularly, the flexibility provided by a PPO network is incredibly convenient.
• More Coverage - When someone goes to their family doctor for a once-a-year checkup and has no other anticipated healthcare needs, out-of-network coverage may not be a concern. However, anyone who anticipates health issues will want to consider the increased coverage and money-saving discounts offered only by PPO plans.
• No Referral Restrictions - In an HMO plan, specialist visits and specific treatments require a referral from your primary doctor. In PPO plans, you don’t need a referral to visit a new specialist or schedule an appointment. This makes the process easier and can save you time and stress.

 

How Much Do Medicare Advantage PPO Plans Cost?

The average projected cost of a Medicare Advantage PPO plan in 2023 is $18 a month. However, as with other federal medicare programs, the specific amount paid by the member will depend on annual salary and other factors. Plans can cost as little as $0 or more than $100 per month, so make sure you know your projected monthly cost before deciding on a plan.

Outside of monthly charges, Medicare Advantage plans may also come with deductibles, coinsurance, and varying coverage levels for out-of-network treatments and providers. You will want to take all these factors into account before choosing your insurance plan.

 

Who Can Enroll In A Medicare Advantage PPO Plan?

Medicare is typically meant for seniors over the age of 65 or people who are severely disabled. In order to qualify for enrollment in a California Medicare Advantage insurance plan, you must meet the following criteria:

• Be enrolled in Medicare Part A and Medicare Part B
• Not be enrolled in Medigap

You also must fall into at least one of the following categories:

• 65 or more years of age
• Diagnosed with End-Stage Renal Disease (ESRD)
• Diagnosed with Amyotrophic Lateral Sclerosis (ALS), also known as Lou Gehrig's disease
• Have another qualifying disability

Qualifying disabilities usually require you to have received at least 24 social security or railroad retirement board (RRB) disability insurance payments.

 

When to Enroll in a Medicare Advantage plan

Thankfully, there are multiple enrollment periods for California Medicare Advantage plans.

• Initial Coverage Election Period - This period begins three months before your 65th birthday and ends three months after your 65th birthday. If you have a disability, this period starts three months before or after your 25th month of receiving benefits.
• Annual Election Coverage - This period starts on October 15th every year and ends on December 7th. If you already have an original medicare plan, you can switch to a Medicare Advantage plan during this time. You can also switch between plan types if you are already enrolled in a Medicare Advantage plan.
• Open Enrollment Period - This period begins on January 1st and ends on March 31st of each year. You can switch between Medicare Advantage plans or revert back to an original medicare plan during this time.
• Special Enrollment Periods - You are eligible for special enrollment periods during certain life events. These include losing your job and employer-sponsored health coverage, moving to a new area outside of your service area, being released from jail, or becoming eligible for both Medicare and Medicaid services.

 

How do Medicare PPOs Compare to Original Medicare?

Medicare Advantage plans, including PPO plans, usually offer better benefits than the original medicare coverage options. However, there are some key differences, and original Medicare does have at least one major perk.

• Prescription Drug Coverage - Medicare Advantage plans usually offer at least some prescription drug coverage, whereas original medicare plans do not.
• Additional Health Services - Medicare Advantage plans may offer additional health coverage options such as dental, vision, and hearing. Original Medicare plans only provide basic health benefits.
• Premium Costs - Costs can vary between plans so make sure to compare monthly prices, deductibles, and other financial factors before making a decision. Medicare Advantage plans also offer financial protection with out-of-pocket cost limitations, whereas original Medicare doesn't.
• Coverage Areas - One of the most significant advantages of an original medicare plan is the freedom to get care from any Medicare provider in the country. Medicare Advantage plans are usually limited to a geographic area. If you travel often, this could be a major consideration.
• Government or Private Providers - The government offers original medicare plans. Medicare Advantage plans, on the other hand, are provided by private health insurance companies.

If you have any questions about the process of choosing a plan, feel free to reach out to our Alignment Health Plan team. We’re always happy to take your call and walk you through the options so you can pick the best plan for you.

 

FAQs

Are there Medicare Advantage PPO plans in California?

Yes, California offers Medicare Advantage PPO plans. Not all areas of the country offer this coverage, so make sure you look into the specific offerings for your region before making a decision.

What is the best Medicare PPO plan in California?

There is no one "best" healthcare plan. Each member's needs and coverage requirements vary wildly from person to person. However, there are some top-rated California medicare PPO plans that are especially popular. Many online resources poll patients and providers and compare plans to give each one a star rating. However, while a plan may be highly rated by some users, it doesn't mean it is the best choice for you. Before making your choice, compare the specific coverage, costs, limitations, and coverage areas provided by each plan.

Is a Medicare Advantage Plan the same as a PPO?

Medicare Advantage offers four types of health insurance coverage.

• Medicare Advantage HMO plans require members to seek care from specific in-network providers and necessitate coordination and referrals from a dedicated primary care doctor.
• PPO plans offer patients the flexibility to choose what doctors they'd like to see, the medication they'd like to try, or the treatments they want to move forward with. PPO members don't have to receive a referral before scheduling an appointment and can change doctors or see out-of-network providers while still obtaining at least some level of out-of-network coverage.
• PFFS, or private fee for service, are plans offered by private insurance companies that allow high flexibility. Similar to a PPO but with even more freedom, PFFS plans can be complicated to navigate or expensive because patients manage their own care coordination to an even greater degree than a PPO plan.
• Medicare Advantage Special Needs Plans, or SNPs, are tailored to a specific patient group. Each SNP is available only to members who are diagnosed with a particular disease or health issue. Some of these issues include cancer, diabetes, dimension, and autoimmune disorders.

What does the PPO mean on Medicare Advantage?

PPO stands for preferred provider organization. Preferred provider organization plans allow members to select their preferred healthcare providers and organizations without primary care physician oversight. You can switch PCPs, healthcare systems, or specialists without getting approval. Members are also free to visit a provider who is out of a plan’s network.