Medicare Advantage PPO plans are not all the same. The rules may vary from insurance company to another insurance company.
Below is just an example from one PPO plan’s Evidence Of Coverage.
Some In-Network services require prior authorization from the plan in order to be covered. Obtaining prior authorization is the responsibility of the Primary Care Physician or treating provider.
When you read the actual Evidence Of Coverage you will find a significant number of In-Network medical services require prior authorization. The PPO plan can deny the service. Even when approved, there may be a delay factor before the service can be obtained.
You don’t need to get a referral or prior authorization when you get care from out-of-network providers.
However, if the insurance company later determines that the services are not covered or were not medically necessary, the insurance company may deny coverage and you will be responsible for the entire cost.
If the Out of Network provide does not accept assignment ... this means they can charge you up to 15% over the Medicare-approved amount.
Note: Medicare Insurance information can be overwhelming and confusing to many people. As an independent licensed agent I can explain things to you in simple terms so you feel comfortable making a decision. Then I can help you choose and enroll in a plan that you feel fits your needs.
By the way, it doesn’t cost you any more if you enroll in a Medicare Insurance plan through me as an independent agent versus directly with an insurance company either over the phone or via the Internet, since I get paid by the insurance companies for your enrollment. Plus you will have personalized service by a local agent. If you would like my assistance, please call me at 941-404-5334.
By calling this number, I understand I will be directed to a licensed insurance sales agent.