Medicare Advantage PPO Plans

checkmark Fact checkedContributing expert: Roseann Birch, insurance consultant; Reviewed by: Leron Moore, Medicare consultant - Updated: Nov 03, 2021

 

Everything you need to know if you are considering a Medicare Advantage Preferred Provider Organization (PPO) Plan.

What You Should Know

  • 1 A Medicare Preferred Provider Organization, or PPO, plan is a form of Medicare Advantage Plan (Part C) 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, insurer, 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 Advantage 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 network of preferred providers. Unlike Original Medicare Parts A and B, which are administered by the government, a Medicare PPO plan is offered by a private insurance company that is approved by Medicare. Medicare Advantage Plans can include a wider range of coverage options. PPO plans can vary in scope and cost depending on the extent of coverage, the insurer, , and your area of residence. Your costs are lowest if you receive services from preferred in network providers, but you can choose out of network providers as well.

Advantages of a Medicare PPO Plan

Of the Medicare Part C options, Medicare PPO plans are the most flexible. PPOs allow you to choose doctors, clinics, and hospitals that you want to see versus being restricted to in-network selections only. This can be valuable if you 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. Many PPO plans include prescription drug coverage as well, which is a plus because if you join a PPO, you cannot purchase a separate Part D prescription drug 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. Premiums 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 Social Security or the Railroad Retirement Board (RRB). 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 your area of residence. Not all plans cover all areas; for example, some PPO plans are only offered in certain states or metro areas.  If you relocate to a new area, you may need to enroll in a different Medicare Advantage PPO Plan.  

How much does a Medicare PPO Plan cost?

The cost of a Medicare PPO plan will vary greatly based on location, insurer, and coverage included. Some Medicare Part C PPO plans offer the minimum required coverage, that is, Medicare Part A and Part B benefits. 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, you may have dozens of plans to consider, each at a different price point. This allows for increased flexibility. If you have  limited medical needs and no interest in extended coverage, a PPO plan with a lower monthly premium may suit you.  

There are other costs to consider. Medicare Part B can affect the cost of a Medicare PPO plan. Some plans may cover a portion of the cost of Medicare Part B in Medicare Advantage premiums, but this isn’t universal. If Plan B premiums are not covered, you will still be required to pay these costs on top of your PPO plan premiums. Consider the impact of out-of-pocket expenses, such as deductibles, when evaluating total plan costs. Some PPO plans may have a deductible associated with the prescription drug coverage aspect of the plan, as well as an additional premium. If you choose a PPO, you cannot buy 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, choose your desired Medicare PPO plan. You can search and compare plans from individual providers or by using the plan finder on the Medicare website. If online enrollment is an option, 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. 

Contact Medicare at 1-800-633-4227 to complete the process if you have questions. Be prepared to provide your Medicare number, as well as the date your 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 when 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 when you can change from Original Medicare to Medicare Advantage, or vice versa, or enroll in a new plan.

Who should get a Medicare PPO Plan?

PPO 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. You pay more for these services with a PPO, but with a HMO, they may not be covered at all.
  • 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. Research the different options available in your area and determine whether moving forward with a Medicare PPO plan is the right decision for you. 

roseann headshot
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.

leron headshot
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.