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PPO (Preferred Provider Organization)
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Important Points
A PPO is a Medicare Advantage plan option.
With a PPO plan, you receive your Medicare benefits through the plan, not the federal government.
PPO's do not require you to choose a primary doctor, but in some cases, you may need to obtain referrals depending on the situation.
PPO stands for Preferred Provider Organization. That means the Medicare insurance company has a network of providers that have agreed to see the plan's members at contract-negotiated rates. These network providers will coordinate your care, but you will have the ability to seek care outside of the network at a higher cost to you.
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What is an PPO?
A PPO is a type of Medicare Advantage plan that you can join as an alternative to Original Medicare. With a Medicare PPO you will typically pay lower co-pays if you use providers that are in the network. You are typically not required to choose a primary care doctor or get referrals to see specialist. Every plan has its own set of rules, so be sure to check the plan's Summary of Benefits before enrolling.
A Medicare PPO plan must provide your Medicare Part A & B benefits to you under the plan. Additionally, the PPO plan must include an out-of-pocket maximum cap on your spending. This protects you against catastrophic costs during a year when you are experiencing higher than normal medical costs.
In year, the maximum that any Medicare Advantage plan can set as your out-of-pocket limit is $8,850 per year. This means that in the worst-case scenario, you would only have to pay $8,850 out of pocket for the year; even if you have multiple hospital stays and complicated procedures.
Common Features of PPO Plans
Annual Changes - The benefits, formulary, pharmacy network, provider network, premium and/or copayments/coinsurance may change on January 1st of each year. It is important to read the Annual Notice of Change letter when it is sent each September to make sure you understand the changes your plan may make for the coming year. This can help you decide if you need to make any changes to your coverage.
Extra Benefits- Many PPO plans offer extra benefits for things like dental, vision, hearing or discounted gym memberships. Limitations, copayments, and restrictions may apply.
Freedom- You are not limited by a service area. If you so choose, you can see out-of-network doctors at a higher cost.
Lower Premiums- Premiums are lower than a tradition Medigap plan because you agree to the plan's rules & limitations.
Prescription Drug Plans- Many Medicare PPO plans include prescription drug coverage that satisfies your Part D requirement. You should always check the plan's formulary to ensure that your medications are included in the plan. It is important to know that if you have a Medicare PPO plan with medical benefits only, you are not allowed to have a separate Part D plan. To get coverage for your prescription drugs on a Medicare PPO plan you must choose one that has an integrated Part D plan.
Typical Costs on a PPO plan
When you choose a Medicare PPO plan, you may have some of the following expenses:
You must still pay for Medicare Part B, which is $174.70 per month in 2025. Some people pay more due to higher incomes.
You might pay a monthly premium for the Medicare PPO plan itself. Many plans offer a $0 premium, but it depends on the plan and this can change from one year to the next.
Along the way, there will be co-pays for medical services as you use them. For instance, you might pay $5 for a primary care visit or $30 for a specialist visit. You'll typically pay a hospital co-pay that might be daily or could be one larger co-pay for the entire stay. Some services will have a 20% coinsurance. This is mainly seen for chemotherapy. Each plan outlines its specific set of benefits and co-pays in their Summary of Benefits. Your agent will go over this with you.
Often, Part D drug plans are built into the plan at no additional cost to you.
Which is Better - Medigap vs. Medicare PPO?
The answer to this all depends on your personal preferences. Medigap (Medicare Supplement) plans pay out after Medicare has covered their portion and leave you with very little out-of-pocket costs. Most of the time you won't even have a doctor co-pay. However, Medigap plans are typically more expensive than Medicare PPO plans. It is also important to note that Medigap plans do not cover prescription drugs. If you want prescription drug coverage with a Medigap plan you will have to purchase a separate stand-alone Part D plan for an additional premium.
Medicare PPO plans typically have lower premiums, but you agree to use a network of doctors to get the lowest co-pays. You pay as you go, so there will be co-pays collected from you at the time of each service. These can include doctor visits, hospital stays, surgeries, lab work, diagnostic imaging, durable medical equipment, and more. Some people don't mind this because they prefer to have a lower monthly premium. The tradeoff between these two types of plans generally comes down to how much you want to pay in monthly premiums.
Do I Still Pay for Part B with a Medicare PPO Plan?
Yes! You must be enrolled in both Medicare Part A and Medicare Part B and live in the plan's service area to be eligible for a Medicare PPO plan.
Can I Switch from an HMO to a PPO?
Yes, you can change your Medicare Advantage plan any time there is an available election period. Most times this is during the Annual Enrollment Period that runs from October 15th - December 7th, or during the Open Enrollment Period that runs from January 1st - March 31st. You may qualify for a Special Election Period in certain situations.
More About PPO Plans . . .
Medicare Advantage PPO plans are just one option you have for your Medicare insurance coverage. These are not the same as Medigap plans. The cost and coverage is different, so you will want to understand both types of plans before you make your choice.
Choosing a plan can be daunting. You need to ensure that you will have access to your doctors and the medications that you require. One of our licensed agents that specialize in Medicare plans can do this research for you at no cost. When you enroll with us, we provide support to you when you have questions about how your benefits will pay for certain services or claims. For a free 1-on-1 consultation call us at (866) 440-1885 to determine whether a Medicare PPO plan would be best for you.
Key Points
PPO plans allow you to go out of network. However, you will likely pay higher costs.
Many PPO plans have low or even $0 premiums.
Many PPO plans have built-in Part D prescription drug coverage at no extra cost to you.
Your plan benefits can change from year to year. Review your Annual Notice of Change (ANOC) letter each September.
At Mohring Insurance Services LLC, we are happy to offer assistance with Medicare when you choose to enroll. Give us a call at (866) 440-1885, or to schedule a free consultation, click the link below:
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