AHIP Practice Exam

What can Mrs. Ramos expect when seeing a provider outside her Medicare Advantage PPO network?

1. Access to the same low co-pays

2. Higher cost-share obligations

3. Full coverage for all services

4. No access to these providers

The correct answer is: Higher cost-share obligations

When Mrs. Ramos sees a provider outside of her Medicare Advantage PPO network, she can expect higher cost-share obligations. Medicare Advantage PPO plans typically offer the flexibility to seek care from out-of-network providers, but this comes at a higher cost to the beneficiary. Within the network, members generally enjoy lower co-pays and cost-sharing amounts, which incentivizes the use of in-network services. When opting for out-of-network care, patients often face higher coinsurance, deductibles, or copayment amounts, leading to increased overall expenses. The statements regarding full coverage for all services or no access to providers are incorrect because, while Mrs. Ramos can see an out-of-network provider, it is not at the same cost as in-network and does not guarantee full coverage. Additionally, the notion of having access to the same low co-pays is misleading in this context, as the financial implications vary significantly between in-network and out-of-network providers. Thus, understanding the higher cost-share obligations is crucial for Mrs. Ramos when planning her healthcare services.