Medicare Preferred Provider Organizations (PPOs) must provide you with the same benefits as Original Medicare but may do so with different rules, restrictions, and costs. PPOs can also offer additional benefits. Below is a list of general cost and coverage rules for Medicare PPOs. Remember to speak to a plan representative to learn the details about any plan you are considering.
- Many plans charge a monthly premium in addition to the Part B premium. Plans may charge a higher premium if you also have Part D coverage.
- Plans may set their own deductibles, copayments, and other cost-sharing for services. PPOs typically set fixed copays for in-network services and may charge more if you see an out-of-network provider.
- PPOs set two annual limits on your out-of-pocket costs. One limit is for in-network costs and the other is for combined in-network and out-of-network costs. These limits may protect you from excessive costs if you need a lot of care or expensive treatments.
- For example, your PPO may have an out-of-pocket limit of $1,000 for your in-network costs, and an out-of-pocket limit of $4,000 for your combined in-network and out-of-network costs. You could reach the combined limit by spending $1,000 on in-network services and $3,000 on out-of-network services, or by spending $4,000 on out-of-network services.
- You are not required to select a primary care provider (PCP).
- You can see a specialist without a referral.
- PPOs cover your care if you visit an out-of-network provider or facility. However, you may pay a higher amount for out-of-network services.
- PPOs cannot charge more than Original Medicare charges for certain kinds of care, including chemotherapy, dialysis, and skilled nursing facility (SNF) care. However, PPOs can charge higher copays for other services, including home health, durable medical equipment (DME), and inpatient hospital care.
- Your PPO may offer additional benefits, such as vision, hearing, and/or dental care. Check with the plan directly to learn about coverage rules and restrictions for any added benefits.