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PPO Plans

Preferred Provider Organization (PPO) Plans are a type of Medicare Advantage Plan. They provide network coverage and are an excellent choice for many.

Network coverage

PPO Plans have a network of providers and hospitals that beneficiaries are encouraged to use. When they visit these providers, their insurance will be accepted and coverage will be granted. If the beneficiary goes outside of the network for health services, they may be responsible to pay a larger amount, if not all, of the medical bill.

Medicare PPO Plans - Explained Video Transcript >

Medicare PPO Plans - Explained!

Hi, I'm Jessica Manion at My Healthcare Direct, and in this video I'm going over Medicare Advantage PPO plans, what they are, so that you can make an educated decision on whether or not that might be an option for you.

Preferred Provider Organization (PPO)

A PPO plan stands for “Preferred Provider Organization”. This means a couple of different things in comparison to an HMO plan.  With a PPO plan, these plans typically include in-network and out-of-network benefits as well as you do not have to select a PCP or a primary care provider when you enroll in the plan. These plans can also include prescription drug benefits, dental, vision, sometimes hearing, and some other ancillary products that original Medicare does not cover.


When it comes to the cost of a PPO plan, it's the same as an HMO where you still have to pay your Part B premium, which in 2021 is 148.50 USD to the average income earner. And then you don't really pay anything else for the Medicare Advantage plan. Most PPO plans can have a zero premium.

Now there are some that do have a premium, but for those typically there's a reason why you want to enroll in them. But for the most part, many people tend to enroll in PPO plans that do not have an additional premium to them.

In many cases, your maximum out of pocket with PPO plan tends to be higher than that of an HMO plan, and it looks to be around the maximum for this year (2021) around 7,500 for the year. But there are some plans that have a lower maximum out of pocket that are PPO plans.

In-network and out-of-network benefits?

So when it comes to choosing whether or not a PPO plan might be best for you, some things to consider are if you prefer to have in-network and out-of-network benefits.

That means if you ended up seeing a physician who is not in the network with the carrier that you enroll with, you will be able to still see them, but you will pay a higher cost than if they were in network with your plan. It also does not require you to have a referral in order to see a specialist, unlike many HMO plans where that's usually a requirement before seeing a specialist.

With PPO plans, if you feel like you need to see a specialist, you can do so without a referral from your primary care provider. So, in some cases with the PPO you may have some higher co-pays than you would with an HMO, but it does provide you some more flexibility in your coverage.

So, if you're someone who wants to not worry about the hassle of going through referrals every time and you want to make sure that if you ended up seeing a doctor out of network, you're not out of cost the full bill for seeing that doctor, then a PPO option may be a good fit for you.

Any further questions?

If you have any other questions about HMO or PPO plans, or if Medicare Advantage is the type of plan that's best for you feel free to give us a call at our office at 888-959-1028

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Prescription drugs

Many PPO Plans include prescription drug coverage. Those enrolled in Part C are not able to enroll in Part D.

Primary care doctor

Primary care doctors are not required by PPO Plans. This is partly because PPO Plans do not require referrals to see specialists within the set network. This can save time and money, making it an excellent way to get access to needed health services.

We can help!

Still have questions?

If you’re still not sure whether a PPO Plan is right for you, make an appointment to speak with one of our professionals. We can discuss all your options and help in the decision-making process.

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