Medicare PPO Plans: Costs and Coverage

• by Christian Worstell
• January 12, 2024
• Reviewed by John Krahnert

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.

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

You do not necessarily have to receive covered 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?

42 percent of 2024 Medicare Advantage plans are PPO plans.¹

56 percent of 2024 Medicare Advantage plans are Health Maintenance Organization (HMO) plans.¹

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).

Medicare Advantage plans can offer more benefits that Original Medicare doesn’t cover, though availability varies and plans with these benefits may not be available where you live.

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 monthly premium premium for a 2024 Medicare Advantage plan is $13.24 per month.²

Please note this is a national average, and premium amounts can vary by ZIP code. This average includes all types of Medicare Advantage plans, not specifically PPO plans.

It’s important to remember that the monthly premium is only one component of a plan’s cost, as health plans can include out-of-pocket costs such as deductibles, copayments and coinsurance.

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.

We represent carriers such as Humana, UnitedHealthcare^®, Anthem Blue Cross and Blue Shield, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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.

 

 

​

Read less