MAPD PPO vs Medigap?

[The Medicare Gal]

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.

 

[vic120]

"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

 

[The Medicare Gal]

"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

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.

 

[vic120]

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

 

[Northeast Agent]

Not to mention the higher MOOP...

 

[Chazm]

$40 ppo? I thought you said you had some pretty good PPO’s?

 

[The Medicare Gal]

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?

 

[vic120]

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?

Ok You basically explained the dif between MA and Med supp

 

[The Medicare Gal]

Ok You basically explained the dif between MA and Med supp

Thanks Vic120. I wanted to be sure I didn't forget anything since I don't usually deal with MA PPO plans.

 

[LostDollar]

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.