- Medicare preferred provider organizations (PPO) is one type of Medicare Advantage (Medicare Part C) plan.
- Medicare PPO plans have a list of in-network providers that you can visit and pay less.
- If you choose a Medicare PPO and seek services from out-of-network providers, you’ll pay more.
When you enroll in a Medicare Advantage plan, there are a variety of different plan structures to choose from. Medicare Advantage PPOs are types of Medicare Advantage plans that offer provider flexibility for beneficiaries who need it.
With Medicare PPOs, you’ll receive coverage for any provider you’d like, but you’ll pay less if you use in-network providers and more if you use out-of-network providers.
In this article, we’ll explore all about Medicare PPOs, including what they cover, how they compare to HMOs, and the advantages and disadvantages of enrolling in Medicare PPO plan.
Medicare Advantage plans are Medicare plans that are sold by private insurance companies. All Medicare Advantage plans cover Medicare Part A and Medicare Part B, and many also cover prescription drugs and other additional healthcare needs.
When you enroll in Medicare Advantage, you’ll need to choose a type of plan structure that matches your needs, like a PPO, HMO, PFFS, MSA, or SNP.
Anyone who is enrolled in original Medicare parts A and B is eligible to enroll in a Medicare PPO plan in the state they live in.
How do Medicare PPOs work?
Medicare PPOs offer provider flexibility for people who want coverage for services from both in-network and out-of-network providers.
With a Medicare Advantage PPO, you can visit any provider you’d like. However, the amount that you pay will differ based on whether that provider is in-network or out-of-network.
If you visit an in-network provider for your services, you will pay less than if you visit an out-of-network provider for those same services.
When you enroll in a Medicare Advantage PPO plan, you’ll be covered for:
- Medicare Part A, which includes hospital services, limited skilled nursing facility care, limited home healthcare, and hospice care
- Medicare Part B, which includes medical insurance for the diagnosis, prevention, and treatment of health conditions
- prescription drug coverage (offered by most Medicare Advantage PPO plans)
- dental, vision, and hearing visits
- additional health perks, such as fitness memberships and transportation to medical appointments
Generally, MedicareAdvantage PPO plans will be more costly the more you use out-of-network providers for your services. However, there are some baseline costs that accompany almost all Medicare advantage plans.
Premiums
When you enroll in a Medicare Advantage plan, you will be responsible for the Part B premium, unless your plan covers it. In addition, Medicare PPO plans can charge their own monthly premium, although some “free” plans don’t charge a plan premium at all.
Deductibles
Medicare PPO plans can charge a deductible amount for both the plan, as well as the prescription drug portion of the plan. Sometimes this amount is $0, but it depends entirely on the plan you choose.
Copayments and coninsurance
With a PPO plan, copayment amounts can differ based on whether you visit a doctor or specialist that is in network or out of network. Common copayment amounts range anywhere from $0 to $50 and up.
Medicare Part B charges a 20 percent coinsurance that you will out pay out-of-pocket after your deductible has been met. This amount can add up quickly with a Medicare PPO plan if you are using out-of-network providers.
Out-of-pocket maximum
All Medicare Advantage plans have an out-of-pocket maximum amount that you will pay before they cover 100 percent of your services. With a Medicare PPO plan, you will have both an in-network max and out-of-network max.
Below is a comparison chart for what your costs may look like if you enroll in a Medicare Advantage PPO plan in a major U.S. city.
| Plan name | Location | Monthly premium | In-network deductible | Drug deductible | Copays & coinsurance | Out-of-Pocket Max | Plan Name |
|---|---|---|---|---|---|---|---|
| Aetna Medicare Prime 1 (PPO) | Denver, CO | $0 | $0 | $0 | PCP: $0/visit specialist: $40/visit | $5,300 in-network | Aetna Medicare Prime 1 (PPO) |
| Humana Honor (PPO) | Portland, OR | $0 | $0 | $0 | PCP: $10/visit specialist: $35/visit | $5,000 in-network | Humana Honor (PPO) |
| Blue Medicare Advantage Essential (PPO) | Kansas City, MO | $0 | $0 | $0 | PCP: $0/visit specialist: $20-25/visit | $6,400 in-network | Blue Medicare Advantage Essential (PPO) |
| Aetna Medicare Value (PPO) | Detroit, MI | $0 | $0 | $150 | PCP: $0/visit specialist: $45/visit | $3,425 in-network | Aetna Medicare Value (PPO) |
| Humana Care Extra (PPO) | Atlanta, GA | $0 | $0 | $0 | PCP: $5/visit specialist: $35/visit | $7,550 in-network | Humana Care Extra (PPO) |
| Anthem MediBlue Access Select (PPO) | Hartford, CT | $0 | $750 | $95 | PCP: $5/visit specialist: $45/visit | $7,550 in-network | Anthem MediBlue Access Select (PPO) |
Before you enroll in a Medicare PPO plan, you’ll want to consider the following advantages and disadvantages and how they can affect your quality of care.
Advantages of Medicare PPOs
- PPO plans are a great choice for people who want to keep flexibility in the providers they visit, especially those who want to keep their current doctor.
- In addition, if you need services from a specialist, a referral is not required – and you can even save money by using in-network specialists.
Disadvantages of Medicare PPOs
- Medicare PPOs aren’t as widely available as HMOs, which means fewer plan offerings for beneficiaries. For people who use out-of-network services often, this can cause healthcare costs to add up quickly.
- Most PPO plans also have multiple out-of-pocket maximum amounts. All these additional fees can cause healthcare costs to add up quickly. In addition,
research has also suggested that PPO plans don’t offer as many new benefits as HMO plans do over time.
How do Medicare PPOs compare to original Medicare?
It’s important to consider all your healthcare needs when choosing between a Medicare Advantage plan or original Medicare. When you compare the two plans, you’ll want to consider some of the differences below.
| Part A | Part B | Part D (prescription drugs) | Medigap (supplemental) | Additional coverage | Out-of-state care | Costs | Out-of-pocket max | ||
|---|---|---|---|---|---|---|---|---|---|
| Medicare Advantage PPOs | yes | yes | most times | no | yes | yes | original costs + plan costs | yes | Medicare Advantage PPOs |
| Original Medicare | yes | yes | add-on | add-on | no | yes | original costs | no | Original Medicare |
After you’ve decided which type of Medicare plan will best suit your needs, you can begin to compare plan costs and find a plan that will save you the most money.
If you’re currently shopping around for Medicare Advantage plans, you may have some questions about how Medicare Advantage PPOs work.
Below, you will find some of the most commonly asked questions about Medicare PPO plans.
What is the difference between PPO and HMO plans?
Medicare PPOs are different from Medicare HMOs because they allow beneficiaries the opportunity to seek services from out-of-network providers.
When you visit out-of-network providers with a PPO plan, you are covered but will pay more for the services. When you use out-of-network providers with an HMO plan, you are generally not covered and will pay the full cost for those services.
Can I keep my doctor?
You can continue to visit your doctor with your PPO plan, as Medicare PPOs don’t require that you choose a specific primary care provider (PCP). However, if your doctor is out-of-network, you will pay more for their services.
Do I need a referral to see a specialist?
Unlike Medicare HMOs, Medicare PPOs don’t require a referral for specialist visits. In fact, if you seek services from a specialist in your plan’s network, you will save more money than if you visit a specialist out of the network.
Medicare Advantage PPO plans are a popular Medicare option for enrollees who are looking for more provider freedom than an HMO plan can offer.
PPO plans offer cost savings when using in-network providers, but these costs can quickly add up when out-of-network providers are used. Still, there is no requirement for a PCP and referrals aren’t required for specialists, which is beneficial for those who require flexibility.
Comparing multiple plan offerings in your area can help you choose the best Medicare PPO plan for your needs.