Licensed Insurance Agents: 888-323-1149 TTY: 711
Mon - Fri, 8am - 8pm ET

Medicare Advantage PPO Plans

What is a PPO Plan?

The word “PPO” means “Preferred Provider Organization.” A Medicare Preferred Provider Organization is a type of Medicare Advantage plan (Part C) that is offered to beneficiaries through a private insurance company. These managed care plans require plan members to obtain health care services through one or more of its participating doctors, hospitals, and health care facilities. Members pay less if they receive in-network health care services. Services rendered by out-of-network doctors and facilities may not be covered or may be paid at a lower level than would be the case for an in-network provider.

Do PPO Plans Cover Prescription Drugs?

Like other types of Medicare Advantage plans, PPO plans offer the option to receive prescription drug coverage in addition to regular plan coverage. Plans differ, so beneficiaries should ask if their plan offers this drug coverage. If they want this drug coverage, they must be sure to join a PPO plan that offers prescription drug coverage, because if their Medicare Advantage plan does not provide this coverage, they may not join a separate Prescription Drug Plan (Part D).

What are PPO Doctor Requirements?

Generally, beneficiaries can receive their health care from any doctor or health care provider while enrolled in a PPO plan. These plans have network doctors and providers, but plan members are still given the flexibility to choose out-of-network doctors. Be aware that out-of-network care will cost more for the beneficiary as the PPO plan will cover less of the expenses. Some Medicare Advantage plans require beneficiaries to choose a primary care doctor to coordinate their health care, but PPO plans do not have this requirement. Additionally, referrals from a primary care doctor are not required for a beneficiary to see a specialist. Like with other aspects of care under a PPO plan, using an in-network plan specialist will usually cost less than using an out-of-network specialist.

What do PPO Plans Cost?

PPO plans may require payment of a yearly deductible before beginning to pay for some or all of a beneficiary’s medical bills. After the deductible is paid, beneficiaries normally pay a percentage of their bills, or a co-insurance, and the PPO pays the rest. Beneficiaries are responsible for a monthly premium as well. Even if a service was performed out-of-network, the plan shares in the costs, but the percentages may differ. PPO plans have a Maximum Allowable Amount for services, which is the most it will pay for a certain service. This amount is similar for services performed in the plan’s network or outside of the plan’s network.

Is a PPO Plan Right For You?

A PPO plan may be the right choice if the following conditions apply to you:

  • Your favorite doctor is already a part of the PPO network
  • You want some freedom to direct your own health care but don’t mind working within a list of preferred providers
  • You do not want a primary care doctor because you are sure you can manage your own care

Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare and provide Medicare Part A and Part B coverage. Medicare prescription drug coverage is insurance run by an insurance company or other private company approved by Medicare. A Medicare Supplement plan is a health insurance plan provided by a private company that fills in the “gaps” in original Medicare coverage.

Medicare has neither reviewed nor endorsed this information.