MAPD PPO vs Medigap?

Jun 10, 2019

  1. The Medicare Gal
    Offline

    The Medicare Gal Expert

    Posts:
    44
    Likes Received:
    10
    State:
    California
    I'm new to an area that offers some pretty good PPO MAPD plans. My former area didn't have a good one so I rarely sold it.

    Here's what I know so far regarding PPOs:

    Pro PPO: Supplements don't include prescriptions.

    Con PPO:
    • Out of network costs are higher than in network costs on a PPO. Medigap doesn't have a network.
    • Procedures can require pre-authorization on a PPO. Medigap doesn't require pre-auth.
    • The plan can change in the future and you'd be stuck with MAPD vs a Medigap.

    What are some of the other "gotchas" that I need to know when dealing with MAPD PPOs versus Medigap?
    The plans here look pretty good but I want a client to be stuck with MAPD because of a "con" I wasn't aware of.

    I am already very familiar with HMO MAPD so please don't include those. I'm specifically looking for PPO differences to Medigap.
     
  2. vic120
    Offline

    vic120 Guru

    Posts:
    3,013
    Likes Received:
    780
    State:
    Tennessee
    "I am already very familiar with HMO MAPD so please don't include those. I'm specifically looking for PPO differences to Medigap"

    If you're familiar with HMO then I assume you have pros and cons MA vrs med supp?

    Beyond that Its more HMO Vrs PPO if you already have Med Supp vrs MA
     
    vic120, Jun 10, 2019
    #2
  3. The Medicare Gal
    Offline

    The Medicare Gal Expert

    Posts:
    44
    Likes Received:
    10
    State:
    California

    Yes I'm familiar with HMOs, as I said. I'm looking specifically for PPO differences to Medigap beyond the ones I initially stated. All my prospects watch a video that explains the pros and cons of MAPD vs Medigap before I write an application. The video focusses on HMOs. If someone wants a $40 per month PPO vs a Medigap I want to make sure that they are aware of the gotchas beyond what I mentioned in my original post.
     
  4. vic120
    Offline

    vic120 Guru

    Posts:
    3,013
    Likes Received:
    780
    State:
    Tennessee
    The difference between MA and Medsupp is what you need to know Its mostly the same

    The difference Between PPO VRS HMO is the next question

    In a lot of Area's I work PPO tends to be one, some or all of the following vrs HMO

    Higher Premium,
    Higher copays
    Less extra's

    In exchange for more freedom then HMO

    This is not always the case but most times that is the dif between HMO and PPO
     
    Last edited: Jun 10, 2019
    vic120, Jun 10, 2019
    #4
  5. Northeast Agent
    Offline

    Northeast Agent Guru

    Posts:
    664
    Likes Received:
    398
    State:
    Pennsylvania
    Not to mention the higher MOOP...
     
  6. Chazm
    Offline

    Chazm Guru

    Posts:
    4,951
    Likes Received:
    1,047
    State:
    Florida
    $40 ppo? I thought you said you had some pretty good PPO’s?
     
    Chazm, Jun 10, 2019
    #6
  7. The Medicare Gal
    Offline

    The Medicare Gal Expert

    Posts:
    44
    Likes Received:
    10
    State:
    California
    In CA these are a lot higher (around $80 per month) and the copay for out of network is a percentage (40%).

    Where I am now the premium is $35 to $40 and the copay for out of network is a dollar amount as oposed to a percentage. From my perspective these look a lot better than the CA PPO I had access to before.

    I'm not looking for a comparison of HMOs to PPOs. Thats a simple comparison and can be done on the Medicare.gov website.

    As I said in my original post, I'm looking for PPOs vs Medigap. Especially the cons. A lot of people think that Medigap is a PPO, which of course it isn't.

    So far I'm finding the cons of a PPO MAPD to be:
    • Out of network costs are higher than in network costs on a PPO. Whereas Medigap doesn't have a network so the costs are the same regardless of where you go.
    • Procedures can require pre-authorization on a PPO. Medigap doesn't require pre-authorization.
    • The PPO could deny your claim. If you have original Medicare and the procedure is covered by original Medicare, your claim can't be denied by a Medigap plan.
    • The plan can change in the future and you'd be stuck with MAPD vs a Medigap.
    • However if the company terminated your PPO instead of just changing it to a plan that covers less, you'd qualify for a Medigap plan under guaranteed issue rights.
    Any other differences in Medigap vs PPO MAPD you can think of?
     
  8. vic120
    Offline

    vic120 Guru

    Posts:
    3,013
    Likes Received:
    780
    State:
    Tennessee

    Ok You basically explained the dif between MA and Med supp
     
    vic120, Jun 10, 2019
    #8
  9. The Medicare Gal
    Offline

    The Medicare Gal Expert

    Posts:
    44
    Likes Received:
    10
    State:
    California
    Thanks Vic120. I wanted to be sure I didn't forget anything since I don't usually deal with MA PPO plans.
    :cool:
     
  10. LostDollar
    Offline

    LostDollar Guru

    Posts:
    2,838
    Likes Received:
    600
    State:
    Kansas
    I can't find the thread(s) now, but I believe I have seen suggestions that sometimes MAPD prescription coverage doesn't work out as well as the Medicare Beneficiary might have hoped.
     
Loading...