Medicare Advantage Plans (Part C)

Medicare Advantage plans may combine all Medicare-covered benefits with additional services, depending on the plan.

Medicare Advantage PPO Plans: Know Your Coverage Options

Medicare Advantage PPO Plans, also called Preferred Provider Organization Plans, are a type of Medicare-approved plan from private insurance companies. These plans cover the same services as Original Medicare (Part A and Part B) and often include extra benefits.

This page helps explain what a PPO plan is, how it works, and what to think about when choosing one.

What Is a PPO Plan?

A PPO plan is a Medicare Advantage plan that lets you choose where to get care. You have the option to:

Visit any doctor or specialist who accepts Medicare
Pay less when you use doctors, hospitals, or other providers in the plan’s network
Go out of network for care, but it may cost more
May be able to specialists without needing referrals

What Do PPO Plans Cover?

All PPO plans must provide the same basic services covered by Original Medicare. Many also include extra benefits, such as:

Prescription drug coverage (Part D)
Routine dental care
Vision services, like eye exams and glasses
Hearing care, including tests and hearing aids
Fitness memberships and wellness programs

Each plan is different. It’s important to look at the details to see which benefits are included.

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Understanding Medicare Advantage PPO Plans

How PPO Plans Work

With a PPO plan:

Emergency care and urgent care are always covered, even out of network
You are encouraged to use in-network providers for the lowest costs
You can see providers outside the network, but it may cost more
You do not need to select a primary care doctor
You do not need referrals to see a specialist

Costs in a PPO Plan

Costs can vary based on the plan and how you use it. You may have:

A monthly premium (some plans have $0 premiums)
An annual deductible you must pay before coverage begins
Co-payments or co-insurance for services like doctor visits or lab tests
A yearly limit on out-of-pocket costs
Higher costs when using out-of-network providers

Reviewing a plan’s cost structure helps you avoid unexpected bills.

Is a PPO Plan Right for You?

A PPO plan may be a good option if you:

Are okay with paying a bit more for extra provider choices
Want to see doctors and specialists without referrals
Travel often or live in more than one location
Want flexibility to get care outside the plan’s network

What to Review Before Choosing a Plan

When looking at PPO plan options, consider the following:

Are your current doctors and hospitals in the plan’s network?
Does the plan cover the prescription drugs you need?
What will your monthly premium, deductible, and co-pays be?
What is the maximum out-of-pocket limit for the year?
What services are included as extra benefits?

When are you eligible for a Medicare Advantage plan?

If you’re 65 or older
If you have other Medicare coverage, you can change to Medicare Advantage during annual open enrollment
You may also qualify under other exceptions, such as an eligible disability or chronic condition

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Connect with a licensed sales agent to explore your Medicare Advantage options

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We do not offer every plan available in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.

[[Senior Healthcare Advisors, LLC, ], [in California – SCH Insurance Agency]] represents Medicare Advantage [HMO, PPO and PFFS] organizations [and stand-alone PDP prescription drug plans that have a Medicare contract. Members may receive a monthly or quarterly allowance benefit in the form of a prepaid card to pay for a wide range of approved [healthy groceries] [and] [utilities]. Unused amounts will expire at the end of the month or quarter. Enrollment depends on the plan’s contract renewal.

Eligibility is based on clinical criteria established by the plan. The benefits mentioned in this material may be available as part of a Special Supplemental Benefit for the Chronically Ill (SSBCI) for members with certain chronic conditions. Not all members qualify.

Not all plans offer all of these benefits. Availability and amount of these benefits vary by carrier, plan, location and service area. Not all plans offer SSBCI benefits. Limitations and exclusions may apply. [[Senior Healthcare Advisors, LLC,], [in California – SCH Insurance Agency]] not connected/endorsed by a government entity. You also agree to the Privacy Policy.

SSBCI benefits are available only to qualifying enrollees who meet the criteria for one or more of the following chronic conditions, which may include but are not limited to: congestive heart failure, diabetes, cardiovascular disorders, chronic obstructive pulmonary disease (COPD), and autoimmune disorders.

Enrollment in a plan may be limited to certain times of the year unless you qualify for a Special Enrollment Period or you are in your Medicare Initial Enrollment Period. Enrollment in a Medicare Advantage plan depends on contract renewal.

PPO: Preferred Provider Organization