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!

Steve and Sue Brauer · Answer

This answer is provided in a video format. Watch the agent's video response here: https://medicareagentshub.com/questions/i-picked-a-ppo-for-the-flexibility-but-now-every-time-i-go-out-of-network-the-bills-are-outrageous-whats-the-point-of-even-having-a-ppo#steve-brauer

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

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.

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.

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.

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

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

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

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.

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

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

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

Richard Kozlowski · Answer

This is something that should have been reviewed in detail by your 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 contact me for a no-cost consultation

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

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.

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.

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

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

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, FL, IN & 5 other states

Answered by John Motsinger 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.

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.

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

Kimberly 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.

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.

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.

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.

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.

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.

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

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

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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