Medicare PPO Plans

Medicare PPO plans, formally known as Medicare Advantage PPOs, provide people on Medicare with the freedom to see doctors outside of the plan’s network without needing to pay the full cost of coverage out-of-pocket.

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Because private insurance companies sell Medicare Advantage PPO plans, each plan can come with different costs and features. Medicare PPO plans give you more flexibility in managing your healthcare. However, this option can come at a higher cost than some alternatives.

What is a Medicare PPO?

Medicare PPO plans provide flexibility in healthcare services, as seniors can use both in-network and out-of-network healthcare providers. For those using the network of doctors, hospitals, and healthcare providers, their Medicare Advantage PPO includes receiving an in-network rate for copays, coinsurance, or other costs.

For health services outside of your network, you will pay higher out-of-network costs. Thus, when you enroll in a Medicare PPO plan, you can see any provider you wish, but your costs could be higher when you are outside of your plan’s network.

Each Medicare PPO plan has an out-of-pocket maximum in place to cap your out-of-pocket costs. The carrier sets a specific dollar amount as the most you can spend out of your own pocket for health care through your plan during a calendar year. Once you reach the out-of-pocket maximum, the Medicare PPO plan picks up 100% of your healthcare costs.

Because Medicare PPO plans are available through private insurance companies, the costs, out-of-pocket maximums, and available plan types will vary depending on the insurance company, plan, and service area.

What Does PPO Mean in Medicare?

In Medicare, PPO means Preferred Provider Organization. A Medicare PPO plan is a type of Medicare Advantage plan that allows you to use healthcare providers that are both in and outside of your network. This is why the name Medicare PPO is synonymous with Medicare Advantage PPO, albeit the former is an informal moniker.

When you use doctors and facilities that have enrolled in Medicare, you’ll pay less than you will for that outside of your plan’s network. Nevertheless, both are viable options. Seniors are also covered during trips to urgent care or when in need of emergency services.

Who Can Enroll in a Medicare Advantage PPO Plan?

Joining a Medicare PPO plan is simple. To join a Medicare Advantage PPO plan, you must enroll in Original Medicare (Part A and Part B). If you are enrolling for the first time, you can do so during your Initial Enrollment Period. There is no need for seniors to answer underwriting health questions.

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If you have previously enrolled in Medicare and are looking to switch to a Medicare Advantage PPO plan, you can do so during the Annual Enrollment Period every year from October 15 through December 7.

Remember that if you are outside either of these enrollment periods, you may not change your plan unless you qualify for a Special Enrollment Period. To qualify for a Special Enrollment Period, you’ll need to have a qualifying life event occur, such as moving, losing your coverage, or a change in your Medicare coverage.

Medicare Advantage PPO vs. Original Medicare

Medicare Advantage PPO plans must cover the same types of services as Original Medicare. However, the main difference between the two is that the government administers Original Medicare, while Medicare Advantage plans are available through private insurance companies.

This means that the premiums and out-of-pocket costs for Medicare Advantage PPO plans may vary.
Unlike Medicare Advantage PPO plans, Original Medicare does not have provider networks. You can see any health care provider you want, as long as they accept Medicare assignment.

So, no matter which doctor you see, you will always pay the same price if they are enrolled in Medicare. However, if a doctor does not accept Medicare, you must pay the full cost of services on Original Medicare or a Medicare PPO plan.

Furthermore, doctors can enroll in Medicare without accepting Medicare assignment. In this case, you could have to pay 100% of your healthcare expenses out-of-pocket before waiting for reimbursement from Medicare.

When it comes to Medicare Part B costs, doctors that do not accept Medicare assignment can even bill you for excess charges in many states. Known as balance-billing, these charges can equate to up to 15% over the price Medicare approves for a healthcare service.

When you enroll in Original Medicare, you can also sign up for a Medicare Supplement plan to help cover out-of-pocket costs. However, you cannot get a Medicare Supplement (Medigap) plan at the same time you have a Medicare Advantage plan – including a Medicare Advantage PPO.

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Is a Medicare PPO Plan the Same as an Advantage Plan?

Medicare PPO plans are the same as Medicare Advantage plans. However, it’s important to remember that not all Medicare Advantage plans are PPO plans. A PPO plan under Medicare will be a Medicare Advantage plan, but there are other types of Medicare Advantage plans, such as Medicare Advantage HMOs.

Why Would Someone Choose a PPO for Their Medicare Coverage?

One major reason for picking a Medicare PPO plan is the flexibility. Sure, you’ll have to pay more when receiving healthcare services outside of your network, but your benefits are still available, unlike other plans.

Additionally, when you have a Medicare Advantage plan, you have the same inpatient benefits of Medicare Part A and outpatient benefits of Part B. The difference is that because private insurers provide Medicare Advantage plans, you will receive more coverage than with Original Medicare only.

Whatever your healthcare needs, there are plenty of options available. This means that should a Medicare Advantage PPO plan best suit your needs, it will be the right option for you.

What is the Best Medicare Advantage PPO Plan?

The best PPO Medicare Advantage plan is the one that fit your needs. Remember, all Medicare Advantage plans are available through private companies. Thus, policy benefit guidelines and prices vary.

No singular plan can be a universally accepted as the best option for everyone.

Instead, you should evaluate your healthcare needs to identify which Medicare Advantage PPO plan will be the best fit for you. Speaking with a licensed Medicare agent is a great way to ensure you receive the best coverage.

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How to Enroll in a Medicare PPO Plan

Healthcare costs are rising, so it is more important now than ever to find the right Medicare plan. MedicareFAQ can help by researching the rates for top insurance companies in your area and getting you free quotes on coverage.

We help seniors find the right coverage for their healthcare needs, including finding the best Medicare Advantage PPO plans in their area.

Call us at the number above or fill out our form to start the comparison process. The best Medicare PPO policy for you depends on your situation. Contact us today to make the first step toward coverage that fits your life.

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  1. Preferred Provider Organizations, Medicare. Accessed March 2022.

Kayla Hopkins

  • Content Editor

Kayla Hopkins is an accomplished writer and Medicare enthusiast serving as the Editor of Upon completing her Communications degree from Ohio University, Kayla dedicated her time to understanding the ever-evolving landscape of healthcare. With her extensive background as a Licensed Insurance Agent, she brings a wealth of knowledge and expertise to her writing.

5 thoughts on “Medicare PPO Plans

  1. I have humanachoiceppo. If I choose a dental who does not accept Humana can I get reimbursed? If yes, what is the turn around time for reimbursement and what forms do I need to file?

    1. Justine, reimbursement is on a case-by-case basis. You would need to complete the form and send it to Humana. However, there is no set time frame to hear back about their decision.

  2. Hi Linda! First off, I’m so sorry to hear about the passing of your mother. Medicare Advantage plans do have copays & coinsurance. Without seeing the bills, it would be hard to say for sure, but it seems like the bills coming from UHC are probably the coinsurance and/or copays left over after the Advantage plan paid their portion of your mothers’ medical costs for services received not related to hospice care. That’s one of the biggest disadvantages of Medicare Advantage plans, they choose how much of each service they want to cover. Original Medicare is not responsible for paying any medical bills that were not directly connected to her hospice care. Original Medicare is responsible for all her hospice care bills. UHC is responsible for THEIR portion of your mothers’ medical bills NOT associated with hospice. Then, your mother is responsible for any copays and/or coinsurance that fall under the Advantage plan for services NOT associated with hospice. I hope this helps!

  3. How is a medicare health plan with prescription drug coverage different from a medicare supplemental ins?


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