What is a PPO Medicare Advantage Plan?
A Preferred Provider Organization (PPO) Medicare Advantage plan has a network of preferred providers, but unlike HMO plans, you're not required to stay within the network. You can see out-of-network providers, but you'll pay more than if you used in-network providers.
PPO plans also don't require referrals to see specialists, giving you more direct access to the care you need.
PPO Plan Costs
PPO plans typically have higher premiums than HMO plans, but offer more flexibility. Cost structure:
- In-network care - Lower copays and coinsurance; counts toward in-network out-of-pocket maximum
- Out-of-network care - Higher copays and coinsurance; may have a separate (higher) out-of-pocket maximum
- Out-of-pocket maximum - PPO plans have two maximums: one for in-network care and a combined in/out-of-network maximum
PPO vs. HMO: Which is Right for You?
| Feature | PPO | HMO |
|---|---|---|
| Monthly premium | Usually higher | Usually lower (often $0) |
| Network requirement | Preferred network, but flexible | Must use network |
| Referrals for specialists | Not required | Usually required |
| Out-of-network coverage | Yes (at higher cost) | Emergency only |
| Best for | Those who travel or want flexibility | Those who want lowest costs |
Who Should Choose a PPO Plan?
A PPO Medicare Advantage plan may be a good fit if you:
- Travel frequently and need coverage in multiple locations
- Have specialists or doctors you want to keep who may be out-of-network
- Want to see specialists without getting a referral first
- Are willing to pay higher premiums for more flexibility
- Have complex health needs that require multiple specialists
Frequently Asked Questions
Do PPO Medicare Advantage Plans Require Referrals?
No. PPO plans do not require referrals to see specialists. You can make appointments directly with any specialist, in-network or out-of-network.
How Much More Does Out-of-network Care Cost with a PPO Plan?
It varies by plan, but out-of-network care typically costs 20-50% more than in-network care. The plan's Evidence of Coverage document will specify the exact cost-sharing amounts for in-network vs. out-of-network services.
Are PPO Medicare Advantage Plans Available Nationwide?
Some large insurers offer PPO plans with nationwide networks, which is particularly useful for people who travel or split time between locations. Check the plan's service area and network directory before enrolling.