Key differences between Medicare supplement, PPO plan

Dear Toni: Thank you for teaching us the value of finding the right Medicare option for my husband, Clint, and me. When he retired at age 70 a few months ago, Clint was determined to go with a Medicare Advantage PPO plan because it had a $0 monthly premium. He thought there was no difference between a Medicare supplement and a PPO plan except cost.

Last week Clint received a life-changing diagnosis of terminal lung cancer. Had we chosen the Advantage PPO plan, Clint and his medical team would not be in control of his health care. Please let your readers know of our situation because health care needs can change in a flash. — Raquel, Springfield, Missouri

Dear Raquel: People need to understand the differences between original Medicare with a supplement and Medicare Advantage PPO plans.

With original Medicare, there is not a network of any kind; you have the freedom to use any health care provider or facility that will bill Medicare. The Medicare supplement that you enroll in will pay the out-of-pocket costs not covered by Medicare Parts A and B.

With a Medicare Advantage PPO plan with low premiums, there are lower costs for in-network providers and facilities but higher out-of-pocket costs for out-of-network benefits.

To review 2025 Medicare Advantage out-of-pocket costs, check your new “Medicare & You” handbook or search Medicare.gov.

Most people on a Medicare Advantage PPO plan never consider that they may have to pay an out-of-network provider. But nowadays, many of them are out of network.

Here’s a closer look at the differences between a Medicare supplement and a Medicare Advantage PPO plan:

Medicare supplement

Supplements work directly with original Medicare. Medicare pays its share of the approved amount for medically necessary, covered health care costs.

The supplement you pick will pay its share of the medical claim from your health care provider or facility.

Medicare Part D prescription drugs plans are not included in a supplement. It is important to have your stand-alone prescription drug plan begin the same month as the supplement.

The downside to a Medicare supplement is that the monthly premium can increase each year.

Medicare Advantage PPO

To qualify for any Medicare Advantage plan, you must be enrolled in Medicare Parts A and B and must live in the service area six months out of the year.

Medicare pays the insurance company a specific dollar amount every month for your medical care.

When you go to the doctor, hospital or pharmacist, you must only use your Medicare Advantage plan card, not your Medicare card.

A Medicare Advantage Plan must provide all of your Part A and Part B benefits, and some Medicare Advantage Plans have Part D prescription drug plans included.

Extra benefits such as gym membership or dental and vision coverage may be offered.

Toni King is an author and columnist on Medicare and health insurance issues. If you have a Medicare question, email info@tonisays.com or call 832-519-8664.