Medicare Advantage Coverage Rules For PPOs Appear To Have Vanished From The New Plan Finder

Forbes September 10, 2019
Diane Omdahl

The promotional video for the new Medicare Plan Finder says it was designed to make it easier to learn about and compare coverage options. However, to make an informed decision, one needs to know how a plan would work. For Medicare Advantage plans, coverage rules (specifically, what to do in order for the plan to pay) are important.

There are two coverage rules of concern.

1. Plans can require a referral from the member’s primary physician to see another physician or healthcare provider. Most HMO (health maintenance organization) plans have this requirement but it’s starting to appear in a few PPO (preferred provider organization) plans. Without a referral, the beneficiary either won’t be able to see that provider or...

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