Medicare PPO

Medicare Preferred Provider Organizations (PPOs) are Medicare Advantage plans, much like Medicare HMOs. You will usually be responsible for paying fixed co pays if you use in-network providers. The plan must cover you if you get care out of network. Your costs will be higher if you get care of out the plan's network. PPOs provide Medicare benefits and may offer some additional benefits that Original Medicare does not cover. These benefits can include vision and dental care.

Some states do not have Medicare PPOs. For states that have them, Medicare PPOs are only available in certain areas. Call your State Insurance Department or State Health Insurance Assistance Program (SHIP) to find out if there is a Medicare PPO in your area.

In a Medicare PPO Plan, you pay the following:

The monthly Medicare Part B premium ($96.40 in 2008)

Any monthly premium for coverage for Part A and Part B benefits, prescription drug coverage (if offered), and extra benefits (if offered) above the Medicare Part B premium

Any plan deductible, coinsurance, or co payment amounts that the plan charges. For example, the plan may charge a set amount (copayment) of $10 or $20 every time you see a doctor.

A maximum amount (cap) you have to pay for out-of-pocket costs for both in- and out-of-network care in a Regional Medicare PPO. In a local PPO, the Medicare PPO Plan may or may not choose to have a cap.

How do out-of-pocket costs vary?

Medicare PPO Plans differ in the amount they charge for premiums, deductibles, and services. The PPO Plan (rather than Medicare) decides how much you pay for the covered services you get. Contact the plan before you get services to find out how much you will have to pay and if the service you want is covered. Generally, you will get more benefits for lower costs than Original Medicare. You may also be able to get extra benefits for an additional premium. Every Medicare PPO Plan must cover all medically-necessary covered services, but every plan is different in what you must pay. Contact the Medicare PPO Plan you are interested in to find out more.

Your costs depend on the following:

Which Medicare PPO Plan you choose

Whether the plan charges an additional monthly premium

Whether the doctors, hospitals, and other providers you go to are part of or outside of your plan's network

How much the plan charges per visit

How often and the type of health care you get

Which extra benefits are covered by the plan and how much you pay for them.