Medicare Advantage PPO Plans

checkmark Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Published: September 14, 2020

What You Should Know

  • 1 A Medicare Preferred Provider Organization, or PPO, plan is a form of Medicare Advantage that relies on a specified provider network.
  • 2 Of the Medicare Part C options, Medicare PPO plans are the most flexible.
  • 3 Cost is the primary disadvantage of Medicare PPO plans. These plans tend to be the most expensive of the Medicare Advantage plan types.
  • 4 The cost of a Medicare PPO plan will vary greatly based on location, provider, and coverage included.

There are many different plan types for seniors considering Medicare Advantage, or Medicare Part C, versus Original Medicare. Medicare PPO plans are among the most popular choices for seniors due to their flexibility and ease of use. 

If you are contemplating a Medicare PPO plan in place of Original Medicare Parts A and B, understanding the ins and outs of this plan type is essential. This guide outlines the basics of Medicare PPO plans, their benefits and drawbacks, eligibility for Medicare Advantage, expected plan costs, and enrollment information. 

What is a Medicare PPO Plan?

A Medicare Preferred Provider Organization, or PPO, plan is a form of Medicare Advantage that relies on a specified provider network. Unlike Original Medicare Parts A and B, which are provided through the government, a Medicare PPO plan is offered by a private insurance company. It can include a wider range of coverage options. PPO plans can vary in scope and cost depending on the extent of coverage, the provider, and the area of residence. 

Advantages of a Medicare PPO Plan

Of the Medicare Part C options, Medicare PPO plans are the most flexible. PPOs allow beneficiaries to choose doctors, clinics, and hospitals that they want to see versus being restricted to in-network selections ony. This can be valuable for seniors who travel often and may need help when access to usual facilities isn’t available. PPO plans do not require a set primary care physician, and specialist appointments do not require a referral. Some PPO plans include prescription drug coverage as well, eliminating the need to purchase a separate plan. 

Disadvantages of a Medicare PPO Plan

Cost is the primary disadvantage of Medicare PPO plans. These plans tend to be the most expensive of the Medicare Advantage plan types due to the increased care opportunities, with premiums that can be several hundred dollars more per month than the alternatives. Seniors on a fixed income, or who do not require the level of flexibility provided by a PPO plan, may be better served by choosing an HMO or PFFS option instead. 

Who is eligible for a Medicare PPO Plan?

Seniors who are eligible for Original Medicare are generally qualified to purchase a Medicare PPO plan, which includes seniors over the age of 65 or those who are qualified for disability benefits from the Social Security Administration. For most seniors who meet these basic criteria, getting started with Medicare PPO is as easy as picking a plan and enrolling. 

Location is also a factor for PPO plans. The availability of plans depends on the area of residence. Not all plans cover all areas; for example, some PPO plans are only offered in certain states or metro areas. There is no way to buy a Medicare PPO plan that serves an area where seniors don’t live, regardless of travel plans. Relocating to a new area will require enrollment in a new Medicare PPO plan. 

In some cases, particular health conditions can compromise access to Medicare PPO plans. For example, those with end-stage renal disease are often excluded from standard Medicare Advantage plans in favor of Special Needs Plans. SNPs are designed specifically for those with unique health concerns that can’t be adequately addressed by a PPO plan. 

How much does a Medicare PPO Plan cost?

The cost of a Medicare PPO plan will vary greatly based on location, provider, and coverage included. Some Medicare Part C PPO plans offer the minimum required coverage. In contrast others include a vast array of coverage options, such as travel insurance, vision and dental insurance, prescription drug coverage, and hearing coverage. The more coverage included in a plan, the more it costs. 

No two PPO plans are identical. In areas with large markets, seniors may have dozens of plans to consider, each at a different price point. This allows for increased flexibility. For seniors with limited medical needs and no interest in extended coverage, PPO plans can be similar in price to Original Medicare. 

However, there are other costs to consider. Medicare Part B can affect the cost of a Medicare PPO plan. Some plans include the cost of Medicare Part B in Medicare Advantage premiums, but this isn’t universal. If Plan B premiums are not included, seniors will still be required to pay these costs on top of their PPO plan premiums. Additionally, seniors should consider the impact of out-of-pocket expenses, such as deductibles, when evaluating total plan costs. Some PPO plans may also require the purchase of a separate prescription drug plan. 

How do I enroll in a Medicare PPO Plan?

Enrollment in a Medicare PPO plan isn’t universal, as each provider may have different rules and requirements related to enrollment. In general, however, the steps are often similar. 

First, seniors need to choose their desired Medicare PPO plan. Seniors can search plans from individual providers or by using the plan finder on the Medicare website. If online enrollment is an option, seniors can follow the enrollment instructions on the website. If not, a paper application must be submitted. All Medicare Part C plans must offer a paper application option. Then, seniors can contact Medicare at 1-800-633-4227 to complete the process. When enrolling, seniors must be prepared to provide their Medicare number, as well as the date on which their Parts A and B coverage began.

Enrolling in Medicare PPO plans is only possible during certain enrollment periods. These include:

  • Initial Enrollment Period: A seven-month window that encompasses the three months prior to turning 65, the month of a 65th birthday, and the following three months.
  • General Enrollment Period: An annual window between January 1st and March 31st in which anyone enrolled in a Medicare Advantage plan can switch Medicare Advantage plans or disenroll from a Medicare Advantage plan. 
  • Annual Enrollment Period: An annual window from October 15th to December 7th during which Medicare users can change from Original Medicare to Medicare Advantage, or vice versa, or enroll in a new plan.

Who should get a Medicare PPO Plan?

Many seniors can benefit from a Medicare PPO plan, regardless of age, health, or future arrangements. These kinds of plans are best for those who:

  • Plan to travel and don’t want to be restricted by the more rigid network requirements of an HMO
  • Don’t want to be bound by specialist referrals from PCPs
  • Want more diverse coverage that encompasses extras, such as dental, vision, hearing, and prescription drug coverage
  • Have a larger budget to spend on premium Medicare coverage
  • Don’t want to designate a PCP
  • Don’t want to pay steep costs associated with out-of-network providers
  • Want access to more hospitals and providers

There is no right or wrong answer to choosing a Medicare PPO plan. All seniors have unique medical needs and personal preferences. Seniors are encouraged to research the different options and determine whether moving forward with a Medicare PPO plan is the right decision before enrolling. 

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Contributing Expert:

Roseann Birch, Medicare Consultant

With experience in the insurance field since 1986, Roseann Birch is a seasoned Medicare consultant who is passionate in educating and guiding seniors through their Medicare and Medicare Advantage journey.

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Reviewed by:

Leron Moore, Medicare Consultant

With over 10 years of experience in the Medicare industry, Leron Moore has dedicated his career to effecting change, educating, informing, and resolving issues for Medicare patients and their families.