PPO Plans

Preferred Provider Organization Plans or PPO plans are among the most popular healthcare Medicare Advantage (Part C) plans because they offer their beneficiaries more flexibility in choosing doctors and hospitals at a lower cost. However, beneficiaries will have higher out-of-pocket costs if they go to physicians or hospitals not in the plan`s network. All Medicare Advantage plans, including a PPO plan, are sold by private insurance companies.

Medicare Advantage plans generally must cover hospital and medical insurance that are normally covered under Original Medicare – Part A and B. But often they also provide some additional benefits like dental, hearing, and vision services (DHV services) or prescription drug coverage (Part D of Medicare).

How do PPO Plans work?

PPO Plan doesn’t require the beneficiary to stay in the provided network to get services needed, but if you choose to go out-of-network be prepared to pay out-of-pocket costs. Unlike an HMO plan, Preferred Provider Organization beneficiaries do not need to choose a primary care doctor, nor the referrals to see specialists. However, it is recommended to stay in the plan`s network to avoid additional costs.

PPO Plan Coverage

As mentioned before, every Medicare Advantage plan must offer at least the same benefits that are covered under Original Medicare. However, beneficiaries may be provided with other benefits like:

  • Prescription drug coverage (over-the-counter drugs)
  • Dental, vision, and hearing coverage
  • Fitness benefits through SilverSneakers
  • Meals at the home program – delivered to a beneficiary after an inpatient hospital stay or skilled nursing facility stay
  • Transportation to medical appointments
  • Adult day-care services
  • Nutrition and wellness programs

PPO Plan Costs

All Medicare Advantage plans include deductibles, copayments, or coinsurance for services received. Most Part C beneficiaries have zero dollars monthly premiums. However, as with every Medicare Advantage plan, PPOs also have an out-of-pocket limit maximum they can spend on services. After beneficiaries reach this limit their insurance provider must cover all costs for the rest of the year. In 2022, the maximum out-of-pocket limit for PPOs is 7550$ for in-network services and 11300$ for out-of-network services. Because PPO plans are sold by private insurance companies costs of each plan can vary by each insurance company as well as the service area.

Difference between HMO vs. PPO

There are a few differences between PPO and HMO plans but in general, they are not that different. However, the main differences are:

  • With an HMO plan, you are required to choose a primary care doctor who will manage your every medical need, and with PPO you don’t need to choose a primary care doctor
  • HMO plan requires referrals to see specialist, but PPO plans do not
  • With an HMO plan, you do not get coverage out of network except for emergencies. On the other hand, PPO plans offer you more flexibility in choosing hospitals and doctors outside the plan`s network, but sometimes at higher costs

Who Should Choose A PPO Plan?

Medicare Advantage PPO plan is good for Medicare beneficiaries who:

  • want the flexibility to choose hospitals and physicians without the restriction of a provider network or need for referrals
  • want more additional benefits all in one plan
  • want to have low premiums, sometimes at zero costs
  • are prepared for higher out-of-pocket costs, especially when visiting hospitals out of plan`s network

If you are interested in purchasing PPO Medicare Advantage plans, our experienced agents at Temmen Insurance can help you choose the best option that suits your needs and budget. Call us today and get the best possible coverage for yourself!


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