Medicare PPO Plans: Costs and Coverage

• by Christian Worstell
• October 2, 2023

What is a Medicare PPO?

A Medicare PPO plan consists of a network of preferred health care providers. These are doctors, facilities, pharmacists and other sources of health care services who have agreed to participate in the PPO plan network. There are local PPOs (which tend to have a network more localized to the county or state) as well as regional PPOs (which may have networks that encompass multiple states).

Unlike some other types of Medicare Advantage health plans, a PPO generally does not require you to utilize a primary care doctor, nor do you need a referral to visit a specialist.   

What does PPO stand for?

One common type of Medicare Advantage plan is a PPO, or Preferred Provider Organization plan. Below are some frequently asked questions about Medicare PPO plans.

Do I have to receive care from a preferred provider in my plan network?

You do not necessarily have to seek out services from a health care provider who is part of your plan network, but doing so can typically help you save money on your covered care. By visiting the PPO plan preferred providers for treatment, you will likely pay less money out of pocket, as the plan will typically provide a higher amount of coverage.

Should you seek care from a provider who is not part of your Medicare PPO plan network, you may be subject to higher costs for your care. However, out-of-network care may still be covered to some extent.

How common are Medicare PPO plans?

There were 618 Medicare PPO plans available in 2018, which represented about 28 percent of all available Medicare Advantage plans.¹ As of 2018, every state except Alaska, Delaware, Minnesota, New Hampshire, North Dakota and Wyoming offered at least one local or regional Medicare PPO plan. Other common plans include HMOs, PFFSs, and SNPs. 

In 2017, more than 6.2 million people were enrolled in a local or regional Medicare PPO plan, which represented more than a third of all Medicare Advantage plan holders.²

What do Medicare PPO plans cover?

By law, Medicare Advantage plans must provide at least the same basic coverage as Medicare Part A and Part B (also known as Original Medicare). Hospice care is still covered by Medicare Part A even if you are enrolled in a Medicare Advantage PPO plan.

Where Medicare Advantage plans distinguish themselves is with the extra benefits they each may offer in addition to the required minimum coverage.

Prescription drugs, dental, vision and hearing coverage are among the popular extra benefits that may be offered by some Medicare PPO plans.

What are the advantages of a Medicare PPO plan?

A few reasons why some people might prefer a PPO plan over other types of Medicare Advantage plans include: 

• Medicare PPOs typically offer the freedom and flexibility to seek health care services from providers outside of their plan network, though it will typically be at a higher out-of-pocket cost. This can be especially beneficial to people who frequently travel.
  
  In some health care plans, such as many Medicare HMO plans, you are required to seek covered medical services from a provider within your plan network, with the exception of emergency care or urgent care or dialysis that is outside of your area.
 
• In most cases with PPO plans, you don’t need to obtain a referral in order to see a specialist. Your costs for seeing a specialist in your PPO plan network will most likely be lower than if you use specialists outside of your plan network.
  
  In most cases with many HMO plans, you must select a primary care doctor and seek referrals from them in order to see a specialist.
 
• Many Medicare PPO provider networks tend to be larger than those of other types of health plans. 

Considering the features listed above, a PPO plan could be a beneficial option for someone who values flexibility in their health care decisions.

How much do Medicare PPO plans cost?

The average premium paid by a Medicare Advantage beneficiary in 2018 was $35.55 per month.³ This includes all types of Medicare Advantage plans.

From 2010 to 2017, the average premium paid by a PPO beneficiary in a plan that included prescription drug coverage was $55 for a local PPO, and $41 for a regional PPO.⁴ 

It’s important to remember that the monthly premium is only one component of a plan’s cost, as most health plans typically include out-of-pocket costs such as deductibles, copayments and coinsurance. Medicare PPO plan beneficiaries will typically pay less money out of pocket if they receive care out of their network of providers, however, when compared to beneficiaries of other types of health plans.

Where can I sign up for Medicare PPO plans?

Like all types of Medicare Advantage plans, Medicare PPOs are sold by private insurance companies. The availability and selection of plans will vary from one area to another.

Get in touch with a licensed insurance agent who can provide information on Medicare PPO plans that may be available in your area. A licensed agent can also help you review the costs and benefits of each available plan where you live and help guide you through the enrollment process.  Call 1-800-557-6059 1-800-557-6059 TTY Users: 711 24 hours a day, 7 days a week to speak with an agent.

¹ Kaiser Foundation. Medicare Advantage Plans, by Plan Type. Retrieved from  https://www.kff.org/medicare/state-indicator/plans-by-plan-type/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
² Kaiser Foundation. Medicare Advantage Total Enrollment, by Plan Type. Retrieved from  https://www.kff.org/medicare/state-indicator/total-enrollment-by-plan-type/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
³ MedicareAdvantage.com’s internal analysis of CMS 2018 Medicare Advantage Landscape Source Files. May 2018.
⁴ Kaiser Foundation. Medicare Advantage 2017 Spotlight: Enrollment Market Update. Retrieved from https://www.kff.org/medicare/issue-brief/medicare-advantage-2017-spotlight-enrollment-market-update.

About the author

Christian Worstell is a senior Medicare and health insurance writer with MedicareAdvantage.com. He is also a licensed health insurance agent. Christian is well-known in the insurance industry for the thousands of educational articles he’s written, helping Americans better understand their health insurance and Medicare coverage.

Christian’s work as a Medicare expert has appeared in several top-tier and trade news outlets including Forbes, MarketWatch, WebMD and Yahoo! Finance.

Christian has written hundreds of articles for MedicareAvantage.com that teach Medicare beneficiaries the best practices for navigating Medicare. His articles are read by thousands of older Americans each month. By better understanding their health care coverage, readers may hopefully learn how to limit their out-of-pocket Medicare spending and access quality medical care.

Christian’s passion for his role stems from his desire to make a difference in the senior community. He strongly believes that the more beneficiaries know about their Medicare coverage, the better their overall health and wellness is as a result.

A current resident of Raleigh, Christian is a graduate of Shippensburg University with a bachelor’s degree in journalism.

If you’re a member of the media looking to connect with Christian, please don’t hesitate to email our public relations team at Mike@tzhealthmedia.com.

 

 

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