PPO Plans

Preferred Provider Organization plans, or PPO plans, is a Medicare Advantage Plan that offers a network of doctors, hospitals, and other providers you can choose from. If you decide to use a provider outside of the plan’s network, you may pay more money out-of-pocket.

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What are the benefits of PPO plans?

PPO plans are a type of Medicare Advantage Plan, which means that PPOs must provide the same benefits as Original Medicare. PPOs can also offer additional benefits, such as vision, hearing, and dental services. Other additional benefits include, but are not limited to:

  • Adult day-care services
  • Fitness memberships
  • Nutrition and wellness programs
  • Over-the-counter drugs
  • Services and supports for those with chronic conditions
  • Transportation to doctor visits

You do not have to choose a primary care physician, nor do you need a referral to see a specialist. You can also receive Medicare drug coverage, but you must enroll in a PPO plan that offers that coverage. If you join a PPO plan that doesn’t provide that specific coverage, you will not be eligible for Medicare Part D, the prescription drug plan.

Costs for PPO plans

PPO plans will usually set their own copays within their network services and have the potential to charge more for when you see a provider outside of the network. However, PPO plans will cover your care if you receive it from outside of the network, but your copayments will typically be cheaper when using a provider from within the network. PPOs can also charge more for copayments when it comes to other services such as home health, durable medical equipment, and hospital care as an inpatient.

Keep in mind that PPOs and other Medicare Advantage Plans are not the same as Original Medicare, even though they offer the same benefits. Medicare Advantage Plans can provide additional benefits that may be required for you to pay to receive. They do not work with Medicare Supplements, meaning you’ll be responsible for out-of-pocket costs.

PPOs do have annual limits on out-of-pocket costs. One limit is set for in-network costs, and the other is set for both in-network and out-of-network costs. By having these yearly limits, you can save money from spending too much out-of-pocket, especially if you need expensive care.

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Is a PPO plan right for me?

You might consider investing in a PPO plan if you are looking for the flexibility to choose any medical facility or provider to receive services from, without needing a referral to see a specialist. You also should consider a PPO plan if you’re looking for a portion of your out-of-network claims to be covered.