Introduction

Medicare PPO (Preferred Provider Organization) insurance plans are relatively new to the California insurance market. The first and only statewide Medicare PPO plans are the Anthem Blue Cross Freedom Blue plan options. These Anthem Blue Cross plans emerged in January 2006 and have since been a popular plan selection. Other insurance carriers offer Medicare PPO plans with a service area limited to one or several counties.

Provider Network

Most people are already familiar with PPO health insurance plans. Medicare PPO policies are very similar to the regular individual (non-Medicare) PPO plans, except that Medicare PPO plans have very low or no monthly premiums and lower copayments. Medicare PPO plans, just like the non-Medicare PPO policies, have a robust provider network. Medical services received from network providers are less expensive than medical services received from providers outside the plan network. It is important to stress that Medicare PPO plan members do NOT need a referral or authorization from the insurance carrier in order to see a specialist or receive medical care.

PPO Plan Benefits

Medicare PPO plans have calendar year deductibles and calendar year Out-of-Pocket Maximums. Most major medical services apply to the plan deductible. The insurance carrier reviews each claim that applies to the deductible and requires that the policy holder pay only the Medicare Approved Amount for services rendered. The Medicare Approved Amount is almost always lower than the initial amount requested by a hospital or medical provider. Once a PPO plan subscriber meets the deductible, the plan member then pays either a copayment or fixed percentage for additional medical services. Money spent toward the deductible and after the deductible has been met accrues toward the annual Out-of-Pocket Maximum. Should a plan member reach the Out-of-Pocket Maximum, the remainder of medical services is provided at no charge to the member for the rest of the calendar year. Not all medical services apply toward the plan deductible. Typically, visits to a physician, an annual physical, preventive care visits, vision benefits, and prescription benefits do not apply to the PPO plan deductible. When a specific benefit does not apply to the plan deductible, one makes the prescribed copayment whether the PPO plan deductible has been met or not. Therefore, the structure of Medicare PPO plans allows the subscriber to make a small copayment in order to utilize the policy for common medical services. In addition, this ability to visit physicians, receive preventive care, and obtain prescriptions, all for an affordable copayment, reserves funds for more serious medical care when payment toward the deductible is necessary.

Part D as Part of the Medicare PPO

Finally, another excellent benefit with Medicare PPO policies is the inclusive Medicare Part D prescription benefit. When Part D benefits are part of the policy, one does not need to purchase a stand-alone Part D drug plan. This is advantageous because it saves the Medicare beneficiary time from having to research each distinct Part D plan, and it is also less expensive to the policy holder.

Review PPO Plan Benefits and Obtain a Quote

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