PPO Medicare Health Insurance Plans Guide

Calendar Icon Updated May 07, 2019
Advantage Plans

A Preferred Provider Organization (PPO) Plan is a type of health care plan offered by private insurance companies, including Medicare Advantage (MA), also referred to as Part C. PPO plans give you access to more doctors and other providers than Health Maintenance Organization (HMO) Plans. The plan uses a network of doctors, hospitals, and specialists, but you can pay more to see providers outside of your network.

Usually these types of Medicare plans don’t require you to choose a primary care physician (although you may do so) or get referrals for specialists. These plans are often more expensive than HMO plans because they give you wider provider choice.

What Does PPO Mean For Your Health Insurance?

1. They give you wide provider access.

PPO plans maintain a “preferred” network of providers that contract with the insurance company for lower costs. If you stay in your network and choose participating providers, you’ll pay less than if you go out of network.

Each plan network is unique—some give you access to several preferred providers, while others have slim networks. Before enrolling in this type of plan, check its provider network to see if your doctor is participating.

For emergency situations in which your life or long-term health may be jeopardized without immediate attention, you can visit any emergency room. This also applies to urgent care, such as a sprained ankle, you need while outside of the plan’s service area, including when you travel outside the United States. In these scenarios, you may need to save your bill and then submit a paper claim to your insurance company when you return. The health plan will then consider the claim for coverage.

2. Getting care is simpler with PPO health insurance.

If you need care, you have more access to doctors and specialists with PPO plans vs. HMO plans. Here are the key advantages:

  • You don’t need to choose a primary care physician.
  • You may not need a referral to see a specialist (in most cases).
  • You can see providers outside of the network, although you’ll pay more than you would in-network.
  • Most MA plans, including PPO insurance, have coverage for prescription drugs.

3. Costs can be higher.

PPO plans usually cost more per month than HMO plans because these types of plans have fewer restrictions and allow you greater access to doctors and other providers. Remember, you usually pay less if you choose a doctor who participates in the PPO network.

There’s more to know.

  • Some PPO Medicare Part C Plans include additional coverage like dental and vision care or fitness programs.
  • You can only switch to an HMO plan or another type of insurance during certain enrollment periods.
  • Visit the Medicare website to learn more.

Eligibility Team

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