PPO Plans

Medicare Advantage generally comes in two different types: PPO Plans and HMO Plans. 

PPO Plans have a network of doctors and hospitals. You’ll pay less if you stick to using doctors, hospitals, and other providers within the plan’s network. 

You can go outside the network if you wish, but you will wind up paying more.

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Do PPO plans require me to choose a primary care provider?

No, you do not need to choose a primary care doctor.

Do I have to get a referral to see a specialist?

In most cases you do not need a referral to see a specialist.

You also do not have to use plan specialists, but it will be cheaper if you do so.

What’s the difference between PPO Plans and HMO Plans?

Both have a network of providers. However, PPOs allow you the flexibility to see doctors outside of the network. However, it may cost you more in coinsurance. 

PPOs also do not require you to choose a primary care provider or get referrals to see specialists. HMOs do.

Because of the added flexibility and freedom, PPOs will normally have a higher premium.

What do Medicare Advantage PPO plans cover?

Medicare Advantage plans take over for your Part A and B coverage. So, they’ll cover Part A benefits: inpatient hospital care, skilled nursing facility care, home health care and hospice care. 

They also cover Part B benefits: medically necessary services and preventive services.

However, they provide additional benefits not covered by Parts A and B like an out-of-pocket maximum limit and: 

  • Adult day-care services
  • Dental
  • Fitness memberships
  • Hearing
  • Nutrition programs
  • Prescription drugs
  • Over-the-counter drugs
  • Services and supports for those with chronic conditions
  • Transportation to doctor visits
  • Vision
  • Wellness programs

However, benefits your plan offers will vary based on where you live.