A Preferred Provider Organization (PPO) is a type of Medicare Advantage plan (Part C) offered by a private insurance company. PPO plans typically require plan members to obtain health care services through one or more of its participating doctors, hospitals, and health care facilities. You pay less if you use providers that belong to the plan’s network. But unlike the more restrictive HMO plan option, you can still opt to seek care from an out-of-network provider for a higher copay or coinsurance.


How Medicare Advantage Preferred Provider Organization (PPO) Plans Work

Medicare Advantage PPO plans must offer all benefits covered under Parts A and B of Original Medicare but typically will offer additional benefits above and beyond those.  Most PPO plans offer Part D Prescription Drug benefits. But it is important to note that if you are enrolled into an MA only PPO plan and you want or need prescription drug coverage you will be unable to add a stand-alone Part D Prescription Drug plan.

PPOs are limited in how much they can charge you for copays but for some types of care they may charge more than Original Medicare. The types of care that usually fall under this category include home care and skilled nursing facility services.

Like other types of Medicare Advantage plans, PPO plans must have an annual, maximum out-of-pocket (MOO) limit on how much you are at risk to pay out of your own pocket. PPO plans have two different out-of-pocket limits for in-network and out-of-network care. With the in-network MOOP typically being low and the out-of-network MOOP close to the Medicare allowable amount.  These limits help protect you from excessive costs if you use a large amount of care in any given year or need expensive treatments.

In traditional Medicare Advantage form, emergency services are covered under in-network costs regardless of where care is received. Some PPO plans will also offer coverage in foreign countries for individuals who enjoy traveling.


Can You See Any Doctor with a Medicare Advantage PPO Plan?

In most cases, you can receive healthcare benefits and service from any doctor, other health care provider, or hospital that accepts Medicare with a PPO plan. Just keep in mind, if you opt to receive care outside of the network, you may incur higher copays and coinsurance amounts.


Are Prescription Drugs Covered with a Medicare Advantage PPO Plan?

In most cases, prescription drug benefits are included in Medicare Advantage PPO plans but not all do, and remember, you cannot add a stand-alone Part D prescription drug plan to an MA only PPO plan. If you need prescription drug coverage, you must join a PPO plan that offers prescription drug coverage.


Do You Need a Referral from a Primary Care Doctor Before Seeing a Specialist with a Medicare Advantage PPO Plan?

In most cases, you won’t have to get a referral to see a specialist. The plan’s evidence of coverage document will specify if and when a referral is needed.


How Do I know if a Medicare PPO Plan is Right for Me?

As with any decision made regarding your healthcare, it is important to make sure you are selecting a plan that best fits your own specific needs. Before enrolling into a PPO Medicare Advantage plan, or any Medicare Health Plan, it is a good idea to speak with a licensed sales agent regarding your needs and wants out of a healthcare plan and the different options available to you in your area.

For more information on Medicare Advantage PPO plans or Medicare in general, contact a Medicare Pathways licensed sales agent by calling 866-466-9118.