Medicare PPO’s: What No One Will Tell You

Medicare PPO

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A Medicare PPO is a Medicare Advantage Plan that offers coverage for both in and out of network services. These plans look a lot like the coverage you had when you worked. Usually with more benefits, less out of pockets, and little to no monthly premium.

A PPO plan allows you to visit any doctor without the need for a referral. Other health plans, may be require you to visit your Primary Care Provider (PCP) to get a specialist referral. PPO plans are different… it allows you to bypass this process and doesn’t require you to select a PCP for your health insurance policy.


 A PPO consists of medical professionals and facilities such as primary and specialty physicians, hospitals and other healthcare professionals. These professionals are contracted by the insurance provider to render subscribed participants’ services at an agreed-upon-subsidised cost. In exchange for reduced rates, insurers pay the PPO a fee to access the network of providers.

The insurance company and health service providers negotiate fees and schedules for services. PPO members can use the services of any provider within their network. There’s coverage for Out-of-Network care but that comes at a higher cost. Normally, PPO members pay a co-payment for every visit to their doctor.

As a member of a PPO plan, you’ll be encouraged to use the insurance company’s network of preferred doctors. No matter which healthcare provider you choose, in-network healthcare services will always cost you less. To receive the highest level of coverage, check if your provider accepts your health plan.

In terms of Premiums, PPO plans tend to charge higher premiums because they are more expensive to administer and manage. They have a relatively large network, with preferred providers in many cities and states.


Given the fact that PPO plans offer the most flexible coverage for the insured, you may eventually realise that they have the most expensive monthly premiums. The average monthly cost of a PPO health insurance plan for a 40-year-old $561, which is 15% more expensive than other healthcare policies.

Before the insurance company starts covering for your medical expenses, you will have to pay up an annual deductible. You may also have a co-payment of about $10 – $30 for certain services or be required to cover a certain percentage of the total charges for your medical bills.

Even though a PPO plan is typically the most expensive health insurance policy in the market, you do not have to disregard it as one of your options because despite its cost, it remains the most flexible option. For example, for a person who has special health needs such as back pain that requires a visit to a specialist chiropractor, a PPO policy will be most useful.

Things to know when Choosing a PPO Plan?

  • In PPO plans you do not need to choose a primary care doctor
  • You do not need a referral to see a specialist in most cases, but costs for covered services will be lower if you make use of the plan’s specialists (in-Network) than if you make use of non-plan specialists (Out-of-Network)
  • Prescription drugs are covered by PPO plans in most cases. You should inquire first when choosing a plan. If you need Medicare drug coverage, you must join a PPO Plan that offers prescription drug coverage. Note that, if you join a plan that doesn’t offer prescription drug coverage, you can’t join a Medicare drug plan (Part D)
  • Because most providers are preferred, you save money by using them.
  • PPO plans offer extra benefits than Original Medicare but you may have to pay extra for these benefits.
  • In PPO plans, you can get your healthcare from any doctor, other health care provider, or hospital. Each plan gives you flexibility to go to doctors, specialists, or hospitals that aren’t on the plan’s list but this will definitely attract more cost.
  • A PPO will most likely require you to get pre-authorization for non-emergency services. Prior authorization is a way a PPO makes sure its only paying for healthcare services that are really necessary, so the insurers might require you to get pre-authorisation, and if you don’t get it, the PPO can reject your claim. It is therefore important to read the details of your policy just to know if you’ll require prior authorization before receiving certain medical services. 


Medicare PPO

A PPO plan is a great choice for individuals with offices in more than one state or region because it offers you national network access, with the same benefits available to all members regardless of their location. In this regard, a portion of your out-of-network claims will be covered by your insurance company.

It gives you a large network to chose from and an array of doctors and specialists. Also, as a PPO member you do not require a referral to see a specialist and this eliminates unusual delays in receiving care especially during emergencies. 

A PPO plan will be good for you if you are one who constantly utilizes healthcare services because it gives you the freedom to choose any medical facility or provider of your healthcare needs.


Medicare PPO


  • You do not have to select a primary care Physician
  • The plan allows you to get any doctor of your choice but offers discounts to those within their preferred network
  • You do not need referrals to see a specialist.
  • PPO plans offer more flexible options
  • The plan allows you greater control over your choice as long as you don’t mind paying for them.
  • On the whole, PPOs are the lest restrictive plan. You get to see whomever you want, whenever you want. PPO plans are the definition of freedom and empowers you to make your own choices.


  • The plan charges higher monthly premiums compared to other plans. 
  • Most PPO plans have a set deductible that you must meet before the insurance company will make payments on your behalf. Once your deductible is met, you’ll still be responsible for a percentage of each and every visit in the form of coinsurance. As a result, your yearly health care costs can fluctuate greatly overtime.
  • Higher out-of-pocket expenses
  • Requires close monitoring of in-network and out-of-network coverage to control cost


Medicare PPO

Other Medicare plans like Health Maintenance Organisations, Exclusive Provider Organisations and Point of Service Plans differ from PPOs and from each other in several ways. PPOs are the most common type of healthcare in the employer-sponsored health insurance market, while HMOs lead the way in he individual insurance market. HDHPs make up about one-third of employer-sponsored plans and are seen as lower-cost health insurance options for employers for a couple of years now. POS and EPO plans are options, but they’re not as common as HMOs PPOs and HDHPS. PPO pans offer flexibility and a large network of providers but you should be ready to pay more upfront via premiums. However, if you do not care about having a large network of providers, but want to make sure you pay much less for healthcare, then an HMO will suit adequately into your plan.

PPO Plans charges an average premium of $1335 and an average deductible of $1204. This is in contrast to HMO plans that charge $1212 and $1201 for premiums and deductibles respectively. For POS plans, the cost is way higher as they charge an average premium of $1419 and an average deductible of $1714. Whatever you choicest Medicare Advantage plan is, ensure it meets your healthcare needs.