I picked a PPO for the flexibility, but now every time I go out of network the bills are outrageous. What's the point of even having a PPO?

Question

Carmen Zorrilla · Accepted Answer

I totally understand your frustration!

Having a PPO (Preferred Provider Organization) plan is supposed to give you flexibility and freedom to choose your healthcare providers, both in-network and out-of-network. But, when the out-of-network bills start piling up, it can be overwhelming.

The point of having a PPO is to have access to a wider network of providers, including specialists, without needing a referral. However, it's essential to understand that out-of-network care usually comes with higher costs.

To avoid surprise medical bills, it's crucial to:

- Carefully review your PPO plan's network and coverage
- Verify the network status of your healthcare providers
- Understand the out-of-network costs and billing procedures

If you're feeling overwhelmed or unsure about your PPO plan, I'm here to help!

As a licensed health insurance broker, I can guide you through the complexities of Medicare and health insurance. Let's work together to find a solution that fits your needs and budget.

Call me today to schedule a consultation. Let's navigate the healthcare system together and find a plan that gives you the flexibility and affordability you deserve!

Gary Church · Answer

Hello, my name is Gary Church. My company is Bay Area Health Solutions. I specialize in helping folks navigate through Medicare. A question just came in asking, "I picked a PPO for flexibility, but now every time I go out of network, I get billed outrageously. What is the point of having a PPO plan?"

Well, it gives you the opportunity to go out of network as long as those specialists are willing to bill your insurance company. Your primary doctor has to always be in network with that carrier you're with. But it gives you the option of being out of network to see specialists that might bill your insurance company. They charge a higher co-payment than the specialists that are in network with that Medicare Advantage plan.

But it's up to you. As long as you stay in network, you're going to pay that negotiated rate. So you're either going to pay a co-payment or not pay any co-payment, but you have the flexibility of coming in at a network as long as that doctor is willing to bill that insurance company.

So again, if you want to save money when you're seeing specialists, then you always want to stay in network with that provider. I hope that answers the question. Thank you.

Steve and Sue Brauer · Answer

So the question is that someone picked a PPO for their flexibility, but now every time they go out of network, the bills are outrageous. What's the point of having a PPO? Many times that's the issue. People think they need a PPO when in fact they could get the same, and most times better, coverage with an HMO. Probably nine out of ten people that I spoke or speak to with a PPO are better off in an HMO because their doctors are, in many cases, in the HMO, and the benefits under an HMO are significantly better. The reason for that is when you have a PPO plan, the company has to cover you for out-of-network benefits. That means there's more risk for the insurance company, and because of that, they're going to pull back on benefits for other things. But as far as a PPO goes, when you step out of network many times on a PPO, you're going to have higher out-of-pockets, higher copays most times. It's just not worth it, but everybody's different. It really depends.

Mark Bilgere · Answer

The overall point of the PPO is the flexibility to see a wider range of providers. However, the opportunity to go out of the network comes with increased costs, not at just out-of-network providers, but even the in network providers. The same providers that are in the HMO will cost more if you choose the PPO. So, what's the point?

If you live in or near a major metro area, you probably have very large networks with the large carriers. Unless you have a lot of specialists, or you travel and live in other parts of the country for extended periods (think snowbirds) an HMO will probably work fine for you if you opt for an Advantage plan.

However, if you live in a more rural area, the number of providers and the size of the networks is more likely limited, if there are any at all. If this is the case, then you need a PPO so you can travel to the areas where the doctors are.

One last thing to keep in mind is that just because you have a PPO you are not guaranteed to see any provider you want. Providers can still choose to not accept a plan. Always check with the provider prior to showing up at the office.

Daniel Brechin · Answer

The Idea of a PPO program is to allow you to use Doctors and Hospitals in the network and out of the network.  However,  the increase in the cost of network services is sometimes not explained fully.   When I sell a PPO plan, I make sure all of the Doctors and Hospitals are in network for the plan.  The Out-of-Network services need to be on a need-based basis.  

Danny Brechin 
Contact me.

Lt Col Tim Brown · Answer

A PPO does give you more flexibility of doctors. But like any plan, group, individual or medicare, you still have to check and ask the doctor if they will accept your plan, terms and conditions. If they so no, get a plan they're in or go to a different doc.

Answered by Lt Col Tim Brown on June 16, 2025

Broker Licensed in TN, AL, CO & 10 other states

Answered by Lt Col Tim Brown Medicare Insurance Agent

Pamela Masters · Answer

That must be very frustrating. Being on a PPO does allow you flexibility in choosing providers. With a PPO it still allows you to stay in the network of doctors which is always cheaper but yes PPO’s do charge more for out of network providers. 
You can look at your summary of benefits to see how much you will pay if you decide to go out of network. Each plan is different in their copays so always know how much your particular plan costs you if you do go out of the network. Always know your copays before you sign up for any plan. Ask to see the summary of benefits first. Best of luck.
 Remember you have an opportunity to switch plans 1 time during open enrollment from Jan 1-March 31 of each year if you are in a Medicare advantage plan. Or, during the open enrollment,  you can also go back to original Medicare.

Lynn C Shurtleff · Answer

PPO's give you the flexibility to go out of network provided the provider agrees to accept it as out of network, they are not required to. But most of the time the out of network copays and coinsurance will be higher, often much higher, than using network providers. That's the trade off for the flexibility of having the out of network option.

Answered by Lynn C Shurtleff on August 27, 2025

Broker Licensed in TN, AR, CO & 6 other states

Answered by Lynn C Shurtleff Medicare Insurance Agent

Ray McCauley · Answer

the cost of going out of network is more costly. The ppo can allow some doctors to service you  that may not have been available under a mapd

Steven Graves · Answer

That’s a great and very common question. A PPO (Preferred Provider Organization) plan is designed to offer greater flexibility in choosing healthcare providers, including the option to see specialists and out-of-network providers without a referral. However, that flexibility often comes with higher costs—especially when receiving care outside the plan’s preferred network.

When you go out of network with a PPO, the insurance company typically covers a smaller percentage of the bill compared to in-network care, and you're responsible for the remainder, which can add up quickly. Additionally, out-of-network providers may charge rates well above what the insurer considers "reasonable and customary," leaving you with balance billing.

While PPOs are valuable for those who want or need access to a broader range of providers (especially in situations where in-network options are limited), they may not always be the most cost-effective choice for routine care. If you find yourself frequently needing out-of-network services, it might be worth reviewing your plan or exploring alternative options during the next open enrollment period to better align with your healthcare needs and budget.

Regards,

Serving Texas, Florida and California
Contact me.

Nikki Rowland · Answer

PPOs offer more flexibility compared to HMOs (Health Maintenance Organizations), they still have a cost structure that favors in-network providers. There are many reasons why your out-of-network costs might be so high. 
A PPO simply allows you to go out of network and still get coverage at a contracted rate. An HMO will not cover anything and you will pay everything out of pocket as if you don't have insurance at all.

Nick Mangini · Answer

That is why you need a Medicare Supplement Medigap Plan!  We always advise getting a Medicare Supplement Plan (Medigap) Plan G or Plan N because it allows you to see any Medicare doctor in the US.

Michael Andrews · Answer

So with a PPO plan, it does give you the flexibility to go out of network if absolutely necessary. However, the provider can still decide whether they're going to take the insurance or not. The PPO could be an option if you want to get a second opinion that maybe is not in network and they're willing to bill out of network. But usually, with the contracts, there's no contract with that specific hospital system, so you'll pay it on a network amount.

So if you, for instance, are going to get a surgery done normally with a plan that's in network, maybe you'll have a few hundred dollars copay. However, if you're out of network with a PPO, as an example, sometimes with those plans, you'll pay 20, 30, 40, or even higher percentage of that until you hit the maximum out of pocket. Just keep in mind that each plan typically has its own max out of pocket. If it's an in-network versus out-of-network plan, sometimes you'll see two different max out of pockets for plans.

Regarding HMO, typically with HMO plans, you don't have the extra flexibility. However, if you are in a situation that is an emergency, you will be covered regardless if you're an HMO or PPO or not. I hope this helps.

Cody Biggs · Answer

A PPO gives you permission, not price protection, to go out of network. When you do, the insurer only pays a “reasonable” amount, and the provider can bill you the rest—so costs can explode fast. The real value of a PPO is access to specific doctors, travel flexibility, or second opinions, not routine care outside the network. If you use out-of-network providers often, a PPO usually ends up being an expensive illusion of flexibility.

Answered by Cody Biggs on February 6, 2026

Broker Licensed in LA, AL, AZ & 24 other states

Answered by Cody Biggs Medicare Insurance Agent

Ellen Diehl · Answer

It sounds like you were tricked into an Advantage plan, probably for Zero premium but tons of "free" sounding stuff.   The free dental, vision, etc does not help you when it comes to the big ticket items.  You've made a mistake that you won't be able to fix until next AEP, and even then you will have to go with another dis-Advantge plan which may keep changing every year.  I would have put you with a Supplement Plan G = Good.
 Only VERY healthy people can switch to a Supplement Plan G after IEP or SEP. You have to be able to pass medical underwriting of about 25 medical questions.  Please tell your friends turning 65 not to fall into this terrible trap.

Lilyana Uzdenova-Gomez · Answer

Depending on where you live, you may have a low or no monthly premium for your plan, it may include extra benefits beyond the benefits of the original Medicare parts A and B along with the additional rules and regulations, and it should have a Maximum Out Of Pocket limit which original Medicare doesn’t have. You should also be able to find network providers, depending on where you are located, to take advantage of the lower costs.

Answered by Lilyana Uzdenova-Gomez on February 9, 2026

Broker Licensed in FL

Answered by Lilyana Uzdenova-Gomez Medicare Insurance Agent

Donna Berube · Answer

I know it's very frustrating, try to find Doctors that are in network, and save the PPO part if you need to see a specialist or as a second opinion. You can call member services to find a list of Doctors in network.

Answered by Donna Berube on August 20, 2025

Agent Licensed in NH

Answered by Donna Berube Medicare Insurance Agent

Ron Kaemmerer · Answer

That’s the thing it gives you flexibility to go out of network but in most cases cost 40% of the cost! The best thing to do is to find a plan where all of your doctors are in the network. If you need help I will check all of your doctors to see what is best for you!

Answered by Ron Kaemmerer on December 1, 2025

Broker Licensed in IL, AL, FL, KS, MO & TX

Answered by Ron Kaemmerer Medicare Insurance Agent

Marie Terhune · Answer

Even with a PPO, you want to make sure your agent checks to confirm that your Primary Care Physician and regular specialists are in network because the copayments are higher when you go out of network. However, if you go out of network with an HMO you will be responsible for 100% of the cost!! Therefore a PPO does give you more flexibility and enable you to see out of network physicians without having the complete bill as an out of pocket expense.

Answered by Marie Terhune on May 5, 2025

Broker Licensed in NH

Answered by Marie Terhune Medicare Insurance Agent

Jo Gallo · Answer

Just because the product advises it is a PPO, does not mean you will pay less out of network. Regarding all MAPD Plans - staying in network is the only way to save money. If you would like to look at a different plan, please feel free to contact and I will help you! - Jo Gallo

Answered by Jo Gallo on February 23, 2026

Broker Licensed in NJ, AZ, DE & 8 other states

Answered by Jo Gallo Medicare Insurance Agent

DeVin LeMay · Answer

A PPO lets you see any provider, but out-of-network care often comes with higher coinsurance and no negotiated rates. To save money, try staying in-network whenever possible or ask providers if they’ll accept your plan’s terms.

Answered by DeVin LeMay on November 3, 2025

Agent Licensed in MA

Answered by DeVin LeMay Medicare Insurance Agent

Kirk Doris · Answer

It appears from your question that you elected to enroll in a Medicare Advantage PPO offering. A principal consideration when reviewing Medicare Advantage offers is if the providers you typically utilize are in the plan network. Although PPO options afford a member the ability to seek care from an noncontracted provider - the member is responsible for a much higher copay or co-insurance for that care as well as a significantly higher maximum out of pocket exposure.

Answered by Kirk Doris on August 4, 2025

Broker Licensed in MO, FL, KS, MD & OK

Answered by Kirk Doris Medicare Insurance Agent

Jim Herro · Answer

Your question is more than valid.  What you need to consider when deciding on a PPO is if it is a Passive PPO meaning your out of network medical copays will be the same as in-network copays.

Chris Cole · Answer

The purpose of a PPO is the flexibility of a ppo plan. If you want lower out of pocket cost you should probably pick an hmo plan. But with an hmo you have to stay in network.

Steven Bleicher · Answer

This is among the many reasons why people who are still within their first year of having enrolled into Medicare that spending for a Medicare Supplement ought to be considered. Being within those 1st 12 months exempts you from having to answer the medical questions. You are entitled to a guarantee issued Supplement and the G plan, the N plan and the high deductible G plan should have been considered. Check them out now if you’re new to Medicare.

Answered by Steven Bleicher on April 15, 2025

Broker Licensed in AZ

Answered by Steven Bleicher Medicare Insurance Agent

Steve Houchens · Answer

A PPO will give you freedom to go to any doctor you choose without a referral from a primary care physician but if you go out of network you will pay more out of pocket but PPO plans do have networks just like an HMO the main difference if your primary care physician does not have to direct all your care.

Answered by Steve Houchens on July 12, 2025

Agent Licensed in KY & TN

Answered by Steve Houchens Medicare Insurance Agent

Leslie Kaz · Answer

Great question — and honestly, a really common frustration.
Here's the truth: a PPO does give you the flexibility to go out of network. That's literally the point. But flexibility doesn't mean free — it means you have options, and with those options comes cost-sharing.
What most people don't realize is that PPO plans are designed so you can go out of network in an emergency or when your specialist isn't in-network — not so you routinely bypass your network and wonder why the bill is high.
Here's what a licensed agent would have walked you through before you enrolled:

What your in-network costs look like vs. out-of-network
Which providers and specialists you see most — and whether they're in-network
Whether a PPO was actually the right fit for how you use your insurance

This is exactly why working with a licensed agent matters. It's not just about picking a plan — it's about picking the right plan for your life, your doctors, and your health needs.
A PPO might still be right for you. But the cost is a feature, not a bug — and knowing when to use that out-of-network access (and when not to) makes all the difference.
👉 If you're unsure your plan is the right fit, reach out. That's what we're here for.

Priscilla Ramos · Answer

A PPO gives flexibility to go out of network, but out of network care often costs much more. The main benefit is still lower cost if you stay in network, the flexibility is there, but it comes with higher risks and bills.

Answered by Priscilla Ramos on March 28, 2026

Agent Licensed in OH, AZ, FL & 5 other states

Answered by Priscilla Ramos Medicare Insurance Agent

Michael Yost · Answer

If you had a HMO, the bills would be even higher. HMO's pay $0 for care outside of the network. It's always good to stay in network but at least the PPO does give you flexibility to go in or out of network. Usually, you have a coinsurance for going out of network, which is something better than nothing.

Answered by Michael Yost on April 17, 2025

Broker Licensed in OH, AL, AZ & 27 other states

Answered by Michael Yost Medicare Insurance Agent

Betty McCarty · Answer

A Preferred Provider Organization (PPO) offers several advantages, such as the flexibility to access a wide range of services, including out-of-network care, and typically does not require designating a primary care provider (PCP).

However, a significant disadvantage is the cost associated with receiving care from out-of-network providers, as members are billed additional fees for this privilege.

To mitigate potential billing challenges with a PPO, one option is to select a Medicare Advantage plan with a broad network and strive to stay within that network whenever possible. 

Alternatively, you might consider a Medicare Supplement plan, which generally provides access to a broader network without billing for out-of-network services. Keep in mind, however, that Medicare Supplement plans require payment of a monthly premium, and you will need to purchase a separate prescription drug plan to cover medication expenses.

Please reach out to a local agent to schedule a free consultation if you have additional questions. Many times, talking to a person face to face can make complex issues easier to comprehend.

Don Golding · Answer

There are several reasons a beneficiary might elect to enroll in a PPO. Most PPOs allow you to see a specialist without a referral and have the choice to see an out-of-network provider, should you choose to. With that flexibility comes increased costs, both in-network and out-of-network. Like most things in life, "one-size" does NOT fit everyone; it's the same with healthcare. This is why we highly recommend having a one-on-one appointment with an agent who represents most plans in your area, to find a plan that "fits" you.

Answered by Don Golding on August 28, 2025

Broker Licensed in TX, AL, AR & 5 other states

Answered by Don Golding Medicare Insurance Agent

Frank Woerner · Answer

Medicare Advantage plans are a "network based "plan. This means it is always in a member's best interest to use providers in the plans network, when possible. Unlike most HMO plans, PPO plans do allow a member to go out of network but usually at a higher cost to the member.

Answered by Frank Woerner on October 10, 2025

Broker Licensed in IN & IL

Answered by Frank Woerner Medicare Insurance Agent

Richard Kozlowski · Answer

This is something that should have been reviewed in detail by your agent.

Celeste McGrath · Answer

The point of having a PPO is that when you go out of network, instead of having 0% coverage, you have "some" coverage (percentages and benefits vary from plan to plan). So while you do get bills for those visits, the total cost is less than if you had an HMO and no coverage out of network.

Answered by Celeste McGrath on January 21, 2026

Broker Licensed in GA, FL, NC & SC

Answered by Celeste McGrath Medicare Insurance Agent

Pauline Weiland · Answer

Depending on your state and county and/or lifestyle, this is a tricky answer. PPO offers flexibility, but are also a driving factor in higher costs. Look at alternatives to PPO's. The PPO's as we know them are changing drastically. The insurance industry around Medicare changes annually and you should be working with a local broker to know what is right for your situation.

Answered by Pauline Weiland on April 13, 2026

Agent Licensed in AZ, CA, MS, NV & TX

Answered by Pauline Weiland Medicare Insurance Agent

Tammie Rutledge · Answer

Preferred Provider Organization, each Health Insurance company has a PPO Network and it is prudent to work within that Network if you can. PPO's are more costly for insurance companies because of the Out of Network usage. Try to work within your PPO Network to keep your costs down. Your Local Broker should be able to direct you to a copy of your Local Network of Providers. Your Insurance provider also has ways to search for In Network Physicians.

Answered by Tammie Rutledge on March 29, 2025

Broker Licensed in WA, AZ, CA & 6 other states

Answered by Tammie Rutledge Medicare Insurance Agent

Sandra Kerley · Answer

This is a great question. PPO only allows you to go out of network if the doctor agrees to the terms and conditions of the plan. HMO plans offer no out of network services at all. However, if your going to out of network due to traveling, and you know your travel plans in advance HMO plans are not as tight as they used to be. My mother is on a HMO in SC where we live. She has in network doctors/urgent care places she can go in New York when she visits my brother.

Answered by Sandra Kerley on April 24, 2025

Broker Licensed in SC, IN, NC, OH, VA & VT

Answered by Sandra Kerley Medicare Insurance Agent

Barbara Margucci · Answer

All PPOs are not created equally and have varying copays. For Plans that will offer the same copay for in and/or out of network services, please contact me for a no-cost consultation

Mary Brown · Answer

The advantage of a PPO is flexibility, you can see doctors outside the network without referrals. The downside is that out-of-network care often comes with much higher copays, coinsurance, and bills, which can catch people off guard. PPOs work best for people who want broader access to providers and are comfortable with the potential higher costs.

Answered by Mary Brown on May 19, 2026

Broker Licensed in NJ, DE, FL & NC, OH, PA & TX

Answered by Mary Brown Medicare Insurance Agent

Andrew Kramer · Answer

Clearly the agent who signed you up for the PPO, didn't explain the out-of-net ramifications! The point of having a PPO is not to go out-of-net, but #1 to be sure that most, if not all your Dr's, accept the plan, and #2 not needing referrals to specialists. Personally, I prefer an HMO, much lower co-pays and you still have emergency services across the US - any urgent care and the ER of any hospital.

Answered by Andrew Kramer on June 30, 2025

Agent Licensed in FL

Answered by Andrew Kramer Medicare Insurance Agent

Carol Thompson · Answer

Having a PPO gives you the freedom- flexibility; 
 
With the flexibility and freedom you can travel with your plan but it’s at a higher cost. Higher co payments and co insurance.

Suzanne Lamperti · Answer

A PPO gives one more flexibility than an HMO. You should consider their network area carefully  to avoid large costs. You can also consider an ancillary plan that would help offset those costs.

Jack Mayer · Answer

Many carriers have done away with the PPO side on their Medicare Advantage Plans and its true that if you do have a PPO, your out of pocket is greater than your share of cost in network under the HMO model.

Answered by Jack Mayer on January 5, 2026

Agent Licensed in CA & NV

Answered by Jack Mayer Medicare Insurance Agent

Jennifer Kalbach · Answer

The point of having a PPO over an HMO would be that there is some cost sharing for you with a PPO for out of network. On a straight HMO there is no cost sharing out of network and you would be responsible for the entire amount.

Answered by Jennifer Kalbach on March 16, 2026

Agent Licensed in KY

Answered by Jennifer Kalbach Medicare Insurance Agent

Jaye Maxx Alexander II · Answer

To get the benefits of the PPO and not have the massive surprises of an unexpected bill for an out-of-network doctor, you should look at the ability to get a Medicare Supplement plan. Once you meet the plan's deductible, your plan covers all aspects of the bill. You can speak with an experienced agent who can review and asses your coverage for your lifestyle.

Answered by Jaye Maxx Alexander II on May 26, 2025

Broker Licensed in NC, AK, AL & 47 other states

Answered by Jaye Maxx Alexander II Medicare Insurance Agent

Adam Ernst · Answer

This is a common issue. I have heard from clients and just getting to know people in the Medicare community. It all depends on the carrier. This is why it is better to be on a Medicare supplement that way you do not have to worry about networks. Original Medicare does not have networks and all costs are straightforward. Contact a local agent during Open Enrollment coming up to see if you can switch out of MA. You may not get dental/vision, but your healthcare will be much less and you’ll know your exact costs each month with only 1 yearly deductible with your supplement.

Answered by Adam Ernst on December 17, 2025

Agent Licensed in NC, SC & TN

Answered by Adam Ernst Medicare Insurance Agent

Brent Mowery · Answer

A PPO offers in and out of network coverage. Whereas an HMO is more restrictive. You cannot go out of network on an HMO, or you will pay the entire cost.

Jeffrey Sodikoff · Answer

IF YOU CHOSE A PPO AND KNEW IN ADVANCE YOU WERE GOING OUT OF NETWORK THEN YOU SHOULD HAVE BEEN TOLD THAT BY YOUR AGENT. THESE PPO PLANS ARE NOT DESIGNED TO BE AFFORDABLE FOR OUT-OF-NETWORK BENEFITS. YOU SHOULD ALWAYS STAY IN NETWORK UNLESS THERE IS AN EMERGENCY, AND THEN YOUR HOSPITAL MUST CHARGE YOU AS YOU ARE IN NETWORK FOR ONLY THE EMERGENCY CARE......... NOT FUTURE CARE IF YOU NEED AN OPERATION, ETC. THAT'S WHAT WE AS AGENTS ARE COMPENSATED FOR. YOU CAN ALWAYS CONTACT ME.

Answered by Jeffrey Sodikoff on April 13, 2026

Agent Licensed in FL

Answered by Jeffrey Sodikoff Medicare Insurance Agent

John Motsinger · Answer

Well a PPO does allow you to go out a network whereas an HMO only covers in network do the PPO does offer more flexibility. The best thing to do is work with an agent like myself who has a database that will make sure all your doctors and drugs are covered. This minimizes your chances of going out of network and having bigger bills.

Answered by John Motsinger on August 4, 2025

Agent Licensed in KY, CO, FL & 9 other states

Answered by John Motsinger Medicare Insurance Agent

Glenn Alterman · Answer

Please call me so I can move you to a med sup if you qualify so you won’t have any of the MAPD issues.   
Glenn

Bud Griffin · Answer

If you choose an HMO and go out iof network (without prior approval) you would be responsible for the entire bill.

Kevin Chaikin · Answer

The point is exactly what you stated - you chose it for the flexibility. This is not unusual for a PPO, to pay higher rates when you go out of network. Its in exchange for having that flexibility whereas an HMO is going to cost you less but restrict you more.

Answered by Kevin Chaikin on August 18, 2025

Broker Licensed in VA, AL, AZ & 31 other states

Answered by Kevin Chaikin Medicare Insurance Agent

Chuck Winslow · Answer

This is one of the biggest frustrations I hear from people with PPO Medicare Advantage plans.

A PPO does give you more flexibility than an HMO because you can go outside the network without needing referrals in many cases. But what many seniors don’t realize is that “out-of-network” does NOT mean “covered the same.”

In most PPO plans:
• In-network providers have lower copays and negotiated rates
• Out-of-network providers can charge significantly more
• Deductibles and coinsurance are often much higher outside the network
• Some doctors may not even agree to bill the plan directly

So yes — you technically have access to more doctors, but the financial exposure can become very expensive very quickly.

That’s why understanding the Maximum Out-of-Pocket (MOOP), coinsurance percentages, and provider contracts matters so much before choosing a plan.

For some people, a PPO makes perfect sense because of travel, specialist access, or provider preference. For others, the added costs end up outweighing the flexibility.

This is exactly why I always tell people:
Don’t just choose a plan based on the premium or a TV commercial. The real question is how the plan actually works when you need care.

I help seniors compare these details every day so they understand the tradeoffs before problems happen — always at no cost.

Chuck Winslow
US Marine Veteran 🇺🇸
Retirement & Legacy Planner
Contact me.

Ingrid Kollmann · Answer

The benefit of a PPO is the flexibility to see providers outside the network without needing a referral, but it can be more expensive.

Patrick Stinson · Answer

To me, it sounds more like an HMO rather than a PPO. HMO require in network mainly. PPO should have more flexibility but the cost share for you is more than in network. Just to note, your agent should have asked about this and should have been let known about this (going out of network) and then he should have gone over the cost sharing that may occur. Please don't take this the wrong way but just double check your policy to make sure that you have a PPO and request from whatever Doctor that you are going to see to get it pre approved. That way you will know the cost before you go and can make a decision whether to go with it or decide on somewhere else. I hope this helps! Have a great week!

Answered by Patrick Stinson on March 16, 2026

Agent Licensed in TX, AR, AZ & 9 other states

Answered by Patrick Stinson Medicare Insurance Agent

Kathleen Gonzales-Byrd · Answer

The PPO of a Medicare Advantage plan does allow you to go out of network but there is still a cost associated with going out of network. Typically, the PPO out of network cost represents approximately 40% of the provider (doctor) cost. This percentage can vary by PPO plan. The point of having a PPO is so you can visit a doctor you prefer even if he or she is out of network. But, you must be willing to incur additional cost - versus if you chose to stay IN network. The PPO is intended to allow visits to out of network providers but with additional cost to the member. Comparatively, a Medicare Advantage HMO does not offer any shared cost if you choose to go out of network. It might be in your best interests to locate providers who are in your PPO network.

Answered by Kathleen Gonzales-Byrd on February 9, 2026

Agent Licensed in PA, KS, MD, NJ & NY

Answered by Kathleen Gonzales-Byrd Medicare Insurance Agent

Kim Mitchell-Hargis · Answer

The PPO plans are advantageous to people who don't want to get a referral.  Those who travel a lot and people who have a lot of specialists and need the PPO network.
PPO plans have higher copays and if you do go out of network, you will pay a higher rate.
That is the benefit of having a PPO is that you do have access to out of network.  An HMO you cannot go out of network.  It is your choice... but one that can cost you more if you go with the PPO and go out of the network.

Greg Strasma · Answer

A PPO will allow you to go to any specialist doctor without the need for a referral from your primary care physician anywhere in the country. Personally I have an HMO as the benefits are generally better than with a PPO. And in the states of Georgia and South Carolina if you are with Humana you do not need a referral to see a Specialist doctor.

Answered by Greg Strasma on October 30, 2025

Agent Licensed in GA

Answered by Greg Strasma Medicare Insurance Agent

Sonya Chandler · Answer

A PPO is a great way to see providers who participate with the plan and providers who do to participate with the plan. Yet, when you use non-participating providers the cost is generally higher.

Lakisha Bryant · Answer

Certain PPOs are necessary if you travel out of state. If the provider is out of network, you will pay more for services.

Larry Plyler · Answer

You may have picked a PPO but that PPO is not in the network of your policy coverage.

If you pick a PPO that is in your network, you will receive the substantial discount.

Ira Smith · Answer

PPO plans used to be needed, but now most HMO Advantage Plans allow you to go out of network when you're on vacation & need emergency care or urgent care. In town, yes, you need to be in network, which in most cases is very extensive.

Answered by Ira Smith on April 27, 2026

Agent Licensed in OK

Answered by Ira Smith Medicare Insurance Agent

Brian Williams · Answer

The PPO plan gives you the most flexibility, but the co-pays are higher in exchange for the flexibility. This is something I go over with every client when comparing the PPO with an HMO. What is the core reason for the flexibility? Do you travel a lot? Do you just want to be able to go to any doctor without a referral? If you have a primary care doctor that you are comfortable with and you need the flexibility for Specialist, you may want to compare the PPO with an HMO-POS plan.

Answered by Brian Williams on August 4, 2025

Agent Licensed in FL, AR, CA & 16 other states

Answered by Brian Williams Medicare Insurance Agent

Brian Loquist · Answer

The PPO allows you to at least get some out-of-network coverage. Whereas the HMO will be 100% out of pocket if you do not use the required facility.

Alisa Mathis · Answer

The point of a PPO is to have the option to see providers that may not be in your insurance plan network, but that option will most likely come at a much higher cost than using in-network providers. Insurance carriers negotiate rates with their in-network providers, which allows them to pass down a lower out-of-pocket cost to their members. However, when you go to an out-of-network provider, they don’t have any agreement with your insurance, which means you going out of network may cost your insurance carrier more and makes you responsible for more out-of-pocket cost.

Answered by Alisa Mathis on November 19, 2025

Broker Licensed in PA, IA, ME & 5 other states

Answered by Alisa Mathis Medicare Insurance Agent

Ryan Ross · Answer

PPOs let you go out of network, but they don’t pay as much when you do. That means you pay more if you don’t use doctors in the plan, so it’s flexible, but not always cheap. If you would like me to look over your plan, let me know. I am here to help.

Answered by Ryan Ross on April 15, 2025

Broker Licensed in FL, GA, KS & 9 other states

Answered by Ryan Ross Medicare Insurance Agent

Michael Turkaly · Answer

The whole point of having a PPO network, is it allows you to go in or out of network. It is a lot better and lower copays if you stay in-network. 

A HMO only has in-network benefits, so if you went out of network, you would pay the entire fee.

Julie Hamilton, RN · Answer

I can completely understand your frustration! PPO (Preferred Provider Organization) health insurance plans do typically offer more flexibility than HMO (Health Maintenance Organization) plans because you can get care out of the PPO network but at a higher cost. PPO plans have several key disadvantages. The individual's out of pocket costs are typically higher in a PPO because the doctor/service is not accepting the plans in network compensation These include higher premiums and out-of-pocket costs compared to HMO plans, the potential for uncoordinated care due to lack of a primary care physician, and the responsibility of managing your own care.

Answered by Julie Hamilton, RN on August 27, 2025

Broker Licensed in GA, AL, SC & TN

Answered by Julie Hamilton, RN Medicare Insurance Agent

Tami Baker · Answer

Costs will always be significantly higher with any Plan when you got Out-of-Network. If it was an HMO, you would not have had ANY coverage if it was a non-emergency situation.

You should always try to choose a Plan that has most, if not all of your Medical Providers (including facilities) In-Network to alleviate paying more.

You may need to choose a different Plan or choose Providers that are In-Network to keep costs down. If it is true emergency, you should be able to the closest Urgent Care facility or ER.

Sherita Joseph · Answer

PPOs can go out of network, but the costs are much higher because those doctors don’t have contracts with your plan. The real savings are always in‑network. If you’re running into big bills, that just means we need to look at a plan that actually matches the way you use your care.

Answered by Sherita Joseph on March 30, 2026

Agent Licensed in NC, CO, KY & 7 other states

Answered by Sherita Joseph Medicare Insurance Agent

Charles Wimmer · Answer

I would really question that with your carrier. I have a PPO and it is covered domestically in the US.

Randy Sanchez · Answer

Great question. A question that everyone should ask of themselves regardless of the plan, because by answering you understand why you have it. 
PPO's by nature of design do have a higher cost associated with Out-of-Network use. I recommend staying In-network when at all possible. Going Out-of-network should be only when there is no other option and the physician / attending facility should be will to accept the plans terms and conditions of the plan, and also be willing to bill the plan. 

Thank you

Clarence Davis · Answer

A PPO allows you to visit doctors that normally wouldn't be in network with an HMO. Doctors still have the option to not bill a plan, so make sure the doctor you visit will bill your plan.

Al Bernotas · Answer

Stay in network with the PPO and only go outside of network if you want to have the services of a particular provider. If you really prefer the flexibility, then you should seriously consider a Medigap plan, which would cover you (with rare exceptions) for any services provided by providers who accept Medicare assignment.

Answered by Al Bernotas on November 15, 2025

Broker Licensed in PA

Answered by Al Bernotas Medicare Insurance Agent

Casey Peterson · Answer

Keep in mind that the benefits of a PPO (Preferred Provider Organization) are the flexibility to see providers in and out of network, and normally without a referral required by the plan. However, you normally pay a higher amount out of your pocket when you use out-of-network providers. The best thing to do is to try and use in-network providers.

Answered by Casey Peterson on May 5, 2025

Broker Licensed in ID, AZ, CO & 6 other states

Answered by Casey Peterson Medicare Insurance Agent

Tony Evangelista · Answer

Copays and cost shares will be higher on most PPO's if you go outside of the contracted network. All depends on the setup and the plan details. More of a reason to work directly with a broker to address every provider.

Answered by Tony Evangelista on April 14, 2025

Broker Licensed in IA, AZ, CO & 7 other states

Answered by Tony Evangelista Medicare Insurance Agent

Travis Beaudette · Answer

The PPO plan does offer the flexibility of out of network coverage. With that does come higher copays and coinsurances. Most of the time when clients want that flexibility, you can find a PPO plan that all of the providers you prefer are in network. You shouldn't have to always go out of network. Might be time to look at the plans available to you and see which plan(s) covers most of your providers, or at least has lower out of network costs. This is where a Licensed Medicare Broker can really help you break all of that down.

Answered by Travis Beaudette on August 13, 2025

Broker Licensed in NY, CT & PA

Answered by Travis Beaudette Medicare Insurance Agent

Christopher Cunningham · Answer

This is one of the common outcomes we see with Medicare advantage have you considered going back to original Medicare and using a supplement and drug plan? You have until March 31 to elect that change this year.

Answered by Christopher Cunningham on March 16, 2026

Broker Licensed in OK, AR, AZ & 12 other states

Answered by Christopher Cunningham Medicare Insurance Agent

I picked a PPO for the flexibility, but now every time I go out of network the bills are outrageous. What's the point of even having a PPO?

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I picked a PPO for the flexibility, but now every time I go out of network the bills are outrageous. What's the point of even having a PPO?

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