Medicare PPO Plan Explained

Medicare Advantage PPO plans allow you to see both in-network and out-of-network providers. Here’s how they work.

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A Medicare Advantage preferred provider organization, or PPO, plan is a health insurance plan that offers care through a network of medical providers and facilities. But unlike a health maintenance organization, or HMO, you can seek care outside the network, although it will usually be more expensive. Also, PPO plans typically don’t require referrals to see a specialist.

More than a third (38%) of Medicare Advantage plans are Medicare PPO plans.

How Medicare Advantage PPO plans work

Medicare Advantage is a bundled alternative to Original Medicare and is sold by private health insurance companies contracted with the federal government. Medicare Advantage plans include all the Medicare Part A and Part B benefits, usually prescription drug coverage (Part D), and often additional benefits like some coverage for dental and hearing care.

With a Medicare Advantage PPO plan, you can get affordable care from a network of doctors and hospitals. These medical providers and facilities have contracted with the plan to provide services for specific prices.

PPO plans also allow you to seek out-of-network care. That means you can see any doctor or visit any hospital you want, but you’ll pay more for covered services outside the provider network. In addition, unlike Medicare HMO plans, PPO plans don’t require you to choose a primary care physician or get referrals before seeing a specialist.

Advantages of a Medicare Advantage PPO plan

More flexibility

Because you can seek out-of-network care, you can see any doctor or visit any medical facility you want. This gives you more options, although generally, you’ll want to use in-network care to keep costs down.

No referrals needed

If you want to see an in-network specialist — or out-of-network specialist, for that matter — you can just make an appointment. There’s no need to coordinate your care through a primary care physician.

Disadvantages of a Medicare Advantage PPO plan

More expensive

PPO plans tend to have higher premiums than other types of plans, and there may be a deductible you must meet before the insurance starts covering care.

DIY care management

Although it’s freeing to be able to seek care without the approval of a primary care physician, it also means you’re solely responsible for overseeing your health care. This could be more burdensome if you have complex medical needs.

Who might benefit from a Medicare Advantage PPO plan

A Medicare Advantage PPO plan isn’t the best choice for everyone. Consider a PPO if the following situations apply:

  • You don’t want to get referrals to see a specialist.

  • You want the option of seeking out-of-network care.

  • You can afford the monthly premiums, which may be higher than other plans.

  • You can afford the deductibles, copays and coinsurance required if you seek care.

To compare Medicare Advantage PPO plans (and other Medicare plans), visit Medicare’s plan finding tool.

If you have additional questions about Medicare, visit Medicare.gov or call 800-MEDICARE (800-633-4227, TTY 877-486-2048).
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