What is a Medicare PPO (Preferred Provider Organization)?

Reviewed and Updated by Anastasia Iliou,

A Medicare PPO, or Medicare Preferred Provider Organization, is a type of Medicare Advantage plan. It’s different from other Medicare Advantage plans because while you will select one Medicare preferred provider (doctor), you will have the freedom to use other doctors. Your costs will be cheaper if you use doctors, hospitals, and specialists that are within your PPO network, but you do have the freedom to see several different doctors.

What is Medicare Advantage (MA)?

Medicare Advantage plans are owned and operated by private companies instead of the federal government. This means that though they cover everything that Original Medicare covers, they are allowed to add additional benefits like dental, vision, non-emergency transportation, and even physical fitness.

MA is great for people who are looking for ways to save money on healthcare and have coverage for specialty healthcare services.

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Pros and Cons of Medicare Advantage PPO Plans

Medicare PPO plans are just one type of Medicare Advantage. They are called Medicare “Preferred Provider Organization” plans because even though you will select one provider that is “preferred,” you do have the freedom to see other doctors. This is a huge “pro,” especially for people who see multiple specialists for different healthcare concerns.

It is also a convenient option for people who are not comfortable with the idea of having a strict plan network. If you want to get a second opinion on a health concern, or if you decide you want to switch doctors, it will be easier to do so with a PPO than if you had an HMO plan model.

The downside to having a PPO plan is that PPO options are typically more expensive than other plan types. PPOs usually have higher co-payments; this is the cost of flexibility. A Medicare PPO will usually have a co-payment averaging between $10 and $15 per office visit.

Medicare HMO vs PPO

As mentioned, HMO (Health Maintenance Organization) plans are generally cheaper than PPOs. They are different because HMOs require you to select one primary physician that you visit for all of your healthcare needs; you won’t be able to visit another doctor without a referral.

In most cases, HMOs do not require co-payments when you visit your primary physician. Ultimately, your HMO vs PPO decision will come down to whether costs or flexibility are more important to you.

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PPO Eligibility and Costs

There are very few eligibility limits for Medicare PPO plans. As long as you are eligible for Medicare and reside in an area where a Medicare Advantage PPO plan is available, you probably qualify.

This means that you can qualify for a PPO if you are age 65 or older, have ALS (Lou Gehrig’s Disease), or have been receiving SSDI (Social Security Disability Insurance) for at least 25 months. The only exception to this is for some people who have ESRD (End-Stage Renal Disease). ESRD is the only pre-existing condition that Medicare Advantage PPO plans do not typically cover.

Most PPO plans will charge a monthly premium (in addition to your Part B premium). Costs will vary significantly based on the amount of coverage your plan includes.

For example, a plan that includes prescription drug coverage will have a much higher premium than a plan that does not. You will then have co-payments for most medical services which can range from as little as $10 for a doctors appointment or prescription and up to hundreds for hospital services and procedures. However, there are usually limits on how much you will be asked to pay out of pocket with your PPO plan. This can easily range from $1,000 per year to $4,000 per year or more. Once you hit your out-of-pocket limit, you will be fully covered.

Medicare Advantage PPO Plans Near You

Ready to find a Medicare Advantage PPO (or HMO) plan available in your area? Plans vary by county, city, and even zip code. We can help you look at the options available in your area. To get started, send us a message or give us a call at 844-431-1832.

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