Ron Elledge is a seasoned Medicare consultant and author of “Medicare Made Easy.” As a Medicare expert, he regularly consults beneficiaries on Medicare rules, regulations, and strategies.
Kelly Blackwell is a Certified Senior Advisor (CSA)®. She has been a healthcare professional for over 30 years, with experience working as a bedside nurse and as a Clinical Manager. She has a passion for educating, assisting and advising seniors throughout the healthcare process.
Preferred Provider Organizations, or PPO plans, are a popular type of Medicare Advantage Plan. You can opt for a Medicare Advantage Plan as an alternative way to receive your Original Medicare benefits. PPO plans allow you the flexibility of using in network physicians and hospitals at a lower cost or paying more for out of network providers. Most PPOs include prescription drug coverage and other benefits, such as dental, hearing, and vision.
When you choose a Medicare Advantage PPO plan, you are not required to select a primary care physician or obtain a referral before making an appointment with any out of network provider. You will always get the benefit of a reduced cost if you choose in network physicians or facilities, but you will not be limited to them.
Use this guide to help you understand how Medicare PPO plans work, what benefits they offer, pros and cons, and how to enroll. Costs and availability of plans vary depending on where you reside.
Who Should Get a Medicare PPO Plan?
A Medicare PPO plan may be a good choice for you if you:
- Want the flexibility to choose your Medicare providers without the restriction of a provider network or need for referrals.
- Are willing to pay more if you decide to pursue healthcare out of network. PPOs will still pay a portion of out of network Medicare-covered services, which will apply to your out of pocket maximum cost.
- Want drug coverage with your Medicare Advantage Plan. Many PPOs offer drug coverage. Note: you cannot purchase standalone drug coverage if you have a PPO.
What is a Medicare Advantage PPO Plan?
A Medicare Preferred Provider Organization (PPO) plan is a type of Medicare Advantage Plan, an alternative to Original Medicare. A PPO provides you with access to your Medicare-covered services plus more benefits that Medicare doesn’t cover, such as dental, vision, and hearing. PPOs have a network of providers, but allow for you to pursue out of network services at a higher cost.
|Plan structure||Medicare Advantage Plan with a network of preferred providers. If you stay in network, your costs will be lowest, but you can use out of network providers, too. Referrals are not generally required.|
|Benefits available||All Original Medicare benefits. Usually offers other benefits, such as prescription drug coverage, vision, dental, or hearing.|
|Cost sharing||Plans may have a premium and deductible, but most people have access to at least one zero premium plan in their area. You pay copays for doctor and specialist visits, and copays or coinsurance for drugs and out of network services. Medicare-covered services in and out of network count toward your out-of-pocket max.|
How PPO plans work
MA PPO plans combine the best attributes of a managed care plan and a fee-for-service plan. You have access to a preferred provider network with lower contracted pricing and copays. You also have the flexibility to choose Medicare doctors, specialists, and facilities that are outside the network. Your PPO plan will still pay a portion, but your out of pocket costs will be more.
All Medicare Advantage PPO plans must set an out of pocket maximum amount for in network services and for in and out of network services combined . If you reach that amount, all Medicare-covered services that you receive are free. Premiums, deductibles, copays and coinsurance for drugs, and copays for additional benefits do not count toward your out of pocket max.
Benefits available with a PPO plan
You have all the benefits from Medicare Part A (hospital insurance) and Part B (medical insurance), including:
- Inpatient hospital and skilled nursing facility care
- Home health care
- Medically necessary outpatient care
- Preventive care
Most PPO plans offer additional benefits that Medicare doesn’t cover, like routine hearing, dental, and vision exams. You may have to pay an additional premium to get more comprehensive coverage. For instance, your PPO plan may cover routine dental exams, but you pay more for services like root canals or dentures. Many plans will offer prescription drug coverage. If you choose a plan that doesn’t, you cannot purchase a standalone Part D plan.
|Advantages of a Medicare PPO Plan||Disadvantages of a Medicare PPO Plan|
Compare your Medicare options
See how a Medicare PPO compares to Original Medicare and other Medicare Advantage Plan types.
|Plan type||Costs*||Part A coverage||Part B coverage||Part D coverage||Out-of-state care**|
|Original Medicare||Part B premium||Yes||Yes||No||Yes|
|Medicare Advantage HMO||Part B premium plus plan premium||Yes||Yes||Usually||Emergency only|
|Medicare Advantage PPO||Part B premium plus plan premium||Yes||Yes||Usually||Emergency, plus other care if in your plan’s network, or you pay more for out of network|
|Medicare Advantage PFFS||Part B premium plus plan premium||Yes||Yes||Sometimes||Emergency, plus other care if contracted with your plan and agrees to treat you.|
|Medicare Advantage MSA||Part B premium plus high deductible||Yes||Yes||No||Emergency plus other care but you pay higher cost for out of network if your plan has a network|
|Medicare Advantage SNP||Part B premium||Yes||Yes||Yes||Emergency and out-of-area dialysis plus other care if in your plan’s network|
*All plans include deductibles, copays and/or coinsurance for services received. Medicare Advantage Plans have an out-of-pocket max that applies to Medicare-covered benefits. There is no cap on what you spend for Original Medicare services, but if you purchase a Medigap plan (which has a monthly premium), it will cover most of Original Medicare’s cost sharing requirements.
**Check with your plan for out-of-state coverage and service area.
Who is Eligible for a Medicare PPO Plan?
A Medicare PPO is one of several types of Medicare Advantage Plans available to Medicare beneficiaries. In order to sign up for a Medicare PPO plan, you must first have signed up for Medicare Part A and Part B coverage.
To be eligible for Medicare you must have turned 65 years old and be either a U.S. citizen or a legal resident for at least five years. If you’re under 65, you may also be eligible if you have been receiving disability benefits from either Social Security or the Railroad Retirement Board for a minimum of 24 months. If you’re diagnosed with ALS (Lou Gehrig’s disease) or End Stage Renal Disease (ESRD), you are eligible for Medicare as soon as disability benefits begin.
How Much Does a Medicare Advantage PPO Plan Cost?
You can expect to pay the plan’s monthly premium in addition to your monthly Medicare Part B premium. Many Americans have access to a $0 premium PPO plan with drug coverage. You’re responsible for copayments and coinsurance for each service or drug received, after you have met your deductible. Most PPO plans require copays for services and treatments in network, and coinsurance for services out of network. You pay copays or coinsurance for medications. PPO plans pay for services you receive out of network, but your cost sharing amounts are higher.
See how costs compare for these 2022 PPO plans with drug coverage for a 67 year old female in Chicago, IL
|Plan name||Monthly premium||Deductible||Copay||Coinsurance||Out-of-pocket max|
|Aetna Medicare Value||$0||$0 medical, $0 drug deductible||PCP: $0
|50% out of network||$3,950 in network $8,250 in and out of network combined|
|Cigna True Choice Medicare||$0||$0 medical, $0 drug deductible||PCP: $0
|30% out of network||$4,400 in network $7,550 in and out of network combined|
|Wellcare No Premium Open||$0||$0 medical, $0 drug deductible||PCP: $0
|35% out of network||$3,450 in network $5,150 in and out of network combined|
How Do I Enroll in a Medicare PPO Plan?
To enroll in a Medicare Advantage Plan, you first need to be enrolled in Original Medicare Part A and Part B. After you’re enrolled in Original Medicare, you can enroll in a PPO plan during your Initial Enrollment Period or during other enrollment periods throughout the year:
- Initial Enrollment Period (IEP): This seven-month period starts three months before the month of your 65th birthday, the month of your birthday, and ends three months after your birthday month.
- Initial Coverage Enrollment Period (ICEP): This is the enrollment period for those who want to enroll in a Medicare Advantage Plan and often occurs at the same time as the IEP for Original Medicare.
- Annual Enrollment Period: This period runs from October 15th through December 7th.
- Medicare Advantage Open Enrollment: Medicare beneficiaries who already enrolled in a Medicare Advantage Plan can switch plans between January 1st and March 31st.
Use the Medicare Plan finder to research available PPO plans in your area. When you’ve chosen a plan, go to the insurer’s website to check for online enrollment options or contact the insurance company by phone or email to request a paper enrollment form. You can also enroll by calling Medicare at 1-800-633-4227.
To enroll, you need your Medicare number and the date your Parts A and B coverage began. Your Medicare card has this information.
Who Should Get a Medicare PPO Plan?
Choosing which Medicare Advantage plan is best for you requires careful consideration of your financial and medical circumstances, as well as your personal preferences. If you can afford higher out-of-pocket expenses, want to remain with your existing physician, specialists, and providers and value being able to choose your providers, a Medicare Advantage PPO plan may be the right answer for you.
Learn More From Our Sources
- CMS | Fact Sheet 2021 Medicare Part A & B Premiums and Deductibles | Last accessed January 2022
- Medicare | What Medicare Covers | Last accessed January 2022
- Medicare | Your Medicare Costs at a Glance | Last accessed January 2022
- Medicare | Preferred Provider Organization (PPO) | Last accessed January 2022
- Medicare | Medicare Advantage Plans | Last accessed January 2022
- Medicare | Find a 2022 Medicare Plan | Last accessed January 2022
- SSA | Benefits Planner | Last accessed January 2022