Medicare Preferred Provider Organizations (PPOs) are private companies that the federal government pays to administer Medicare benefits. Like all Medicare Advantage Plans, PPOs must provide you with the same benefits, rights, and protections as Original Medicare, but they may do so with different rules, restrictions, and costs. Some PPOs offer additional benefits, such as vision and hearing care.
Eligibility and costs basics
You must have both Parts A and B to join, and generally you will continue paying your Medicare Part B premium. Your PPO may also charge an additional premium, on top of the Part B premium. If you want Part D coverage, you will receive it through your PPO. Plans may charge a higher premium if you also have drug coverage.
Note: If you join a Medicare Advantage Plan and you want Part D coverage, you must receive coverage from your plan. You cannot enroll in stand-alone Part D coverage unless you join a Medical Savings Account (MSA) or Private Fee-for-Service (PFFS) plan that does not offer prescription drug coverage.
Typically, you cannot have a PPO if you have End-Stage Renal Disease (ESRD), unless:
- You join a Special Needs Plan (SNP) PPO that specifically takes beneficiaries with ESRD
- Or, you were enrolled in a PPO prior to developing ESRD and you choose to stay in that PPO
Note: If you remain enrolled in a PPO after developing ESRD and the plan leaves your area, you have a Special Enrollment Period (SEP) to enroll in another PPO in your area.
Benefits access basics
Once you have joined a PPO, you should receive a benefit card from your plan. You will use your PPO benefit card instead of your Medicare card when you go to the doctor or hospital.
After enrolling in a PPO you can see any provider, but you generally pay more when seeing out-of-network providers. PPO plans typically offer fixed copayments when you use the plan’s network.
There are two types of Medicare PPO plan:
- Regional PPOs, which serve a single state or multi-state areas determined by Medicare
- Local PPOs, which serve a single county or group of counties chosen by the plan and approved by Medicare
Both types of PPO must have a maximum out-of-pocket limit for all of your in-network care and a combined in-network and out-of-network care limit.
Medicare PPOs are not available everywhere. Call 1-800-MEDICARE or your State Health Insurance Assistance Program (SHIP) to find out if there is a PPO available in your area. To enroll in a PPO, call Medicare or the plan directly. Be sure to make an informed decision by contacting a plan representative to ask questions before enrolling.
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