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 at 407-244-6951 to schedule a consultation. Let's navigate the healthcare system together and find a plan that gives you the flexibility and affordability you deserve!

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.

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

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

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

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, FL & ID, MT, OR & TX

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, 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 call me for a no-cost consultation 412-238-2007

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 pic 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.  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.

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.

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.

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

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

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.

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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