What are disadvantages of PPO?

Question

Edward Smith, ChFC, CRPS, AIF · Accepted Answer

Most of the time, all I see is slightly higher co-pays and slightly less extra benefits than HMO plans. The biggest reason to go with a PPO is if you are planning on traveling a lot or have a plethora of medical professionals you see for several different reasons. I hope this helps.

Answered by Edward Smith, ChFC, CRPS, AIF on June 30, 2025

Broker Licensed in OH, GA, IN, KY & TN

Answered by Edward Smith, ChFC, CRPS, AIF Medicare Insurance Agent

Norman Smith · Answer

The PPO’s are limited as to a chosen Network of Doctors and Facilities, where your freedom of selection is restricted. Mostly these come with MA plans. They don’t travel with you easily, and your needs made find you paying for Out of Network Practitioners and hospitals and specialists. 
Now there are “Select” Medigap plans that also give you a PPO option for less cost, but the practicality of those plans seems to be to only offer you a lesser price to limit your choices to their own Network which is one of the main reasons you didn’t go to a MA plans to begin with.

Charise Karjala · Answer

What are the disadvantages of PPO? Two, number one, expense. You have to pay for it. Many people don't have any extra budget other than $185 a month. So they can't afford or don't want to pay for additional expenses. The second item is that there's no coordination of care. So for individuals with chronic illnesses, or who need case management, or who cannot coordinate their services on their own, the HMO is definitely superior. So I leave that with you. And that's it for now.

Christy Jones · Answer

I personally feel that there are more advantages than disadvantages with a PPO. (Although some HMO plans have identical networks to some PPOs) Recently, a disadvantage of a PPO is the increased chance that your plan will be discontinued due to lack of the health insurance company being able to control costs. Some disadvantages of a PPO might be the larger copays compared to HMO
Plans.

Vincent Murray · Answer

There are no disadvantages to being on a PPO. With an HMO however, you either go to in network Doctors or you pay full price. With a PPO plan you pay a lower co pay for in network doctors but you have the freedom to go to an out of network provider and just pay a higher price. As with all plans based on your County A PPO and HMO or HMO POS should be evaluated based on the benefits, Costs and all of your doctors being in network, preferably. At least with a PPO plan you have the option to see out of network Doctors. So there are no disadvantages to being on a PPO.

Answered by Vincent Murray on October 8, 2025

Agent Licensed in ME, FL & NH

Answered by Vincent Murray Medicare Insurance Agent

Michael Andrews · Answer

A couple disadvantages of a PPO are that usually the copays or cost share beneficiaries would have to pay tend to be higher if they go out of network and also some doctors may elect to not accept the out of network benefits and you'd have to pay the full amount.

Answered by Michael Andrews on June 30, 2025

Broker Licensed in CT

Answered by Michael Andrews Medicare Insurance Agent

Patricia &#039;Tif&quot; Bush · Answer

Well, finding one now in Connecticut will be difficult. Major carriers have told us they are taking a pause for 2026 and really don’t want any new business for Medicare advantage. Therefore, if you’re looking at a PPO, I would recommend that you change your thought to a supplement plan. Mainly for the reason that if you go out of network on a PPO, your out-of-pocket max could be up to $10,000. If you go out of network on a supplement plan, you’re out-of-pocket is basically your premium.

Answered by Patricia 'Tif" Bush on September 16, 2025

Broker Licensed in ct, FL, NC & SC

Answered by Patricia 'Tif" Bush Medicare Insurance Agent

Edward MacConnell · Answer

This answer is provided in a video format. Watch the agent's video response here: https://medicareagentshub.com/questions/what-are-disadvantages-of-ppo#edward-macconnell

Randall Taylor · Answer

You will pay more out-of-pocket if you choose an Out-of-Network provider: You will pay a higher copay initially. But the real down side is if you have a catastrophic health event (having used an Out-of-Network provider even just one time in the calendar year), your Maximum Out of Pocket (MOoP) will jump up thousands of dollars.

Answered by Randall Taylor on July 4, 2025

Broker Licensed in TX, MI & WI

Answered by Randall Taylor Medicare Insurance Agent

James Hale · Answer

PPO Plans offer flexibility but that flexibility comes at a price. There are some notable disadvantages when compared to plans like HMOs or EPOs. Some of the main disadvantages of PPO plans are as follows:

1. Higher Premiums: PPO plans typically have the highest premiums, often significantly more than HMOs or EPOs

2. Higher Out-of-Pocket Costs: This includes higher deductibles (the amount you pay before your coverage kicks in), copays, and coinsurance.

3. More expensive out-of-network care — While PPOs provide some coverage for out-of-network providers you will usually pay substantially more for those services. Expect much higher coinsurance, separate deductibles, or reduced reimbursement rates. In some cases, you may be required to pay upfront and file claims for reimbursement on your own. NOTE: Out-of-network providers are not required to write off excess charges like in-network providers are and you can be held liable for them.

4. More Responsibility Managing Personal Care: Without referrals or a designated primary care physician helping coordinate care you're mostly on your own to track provider network status, surprise bills, and handle potential paperwork/claims for out-of-network visits.


NOTE: In recent years PPO options have been disappearing in certain markets (e.g., Medicare Advantage, ACA Marketplace). Networks may be shrinking in some plans and overall costs continue trending higher due to overwhelming administrative costs and fraud. PPOs remain popular for those who value choice, like frequent travelers, those with established out-of-network specialists, or anyone wanting to see specialists without referrals. The trade-off is typically  higher, less predictable expenses. If cost control or more predictable payments matter more then you should consider an HMO or EPO.

Bubi Gorgevich · Answer

PPO usually has higher copays for doctor visits and health services do to a larger network. Other than that has many positive features found by the beneficiaries.

Marc Rheingold · Answer

For a Medicare Advantage Plan PPO:

1. Higher Costs Outside Network: Visiting non-network doctors triggers much higher copays and elevates your maximum out-of-pocket spending limits

2. Prior Authorization Barriers: Insurance companies require pre-approval for many procedures, surgeries, and specialists, causing potential treatment delays or denials.

3. Network and Travel Rules: Plan benefits are tied to specific local counties, meaning non-emergency care is rarely covered when traveling long distances.

Medigap Lock-Out: You cannot buy a Medigap plan to cover copays, and returning to Original Medicare later may be difficult due to medical underwriting.

Nathan Danovski · Answer

PPO (Preferred Provider Organization) health insurance plans offer flexibility in choosing healthcare providers, but they come with several disadvantages. One major drawback is the higher cost—PPOs typically have more expensive monthly premiums, higher deductibles, and greater out-of-pocket expenses compared to other plans like HMOs. Additionally, if you choose to see out-of-network providers, you may face balance billing, where you're responsible for charges not covered by the insurance. PPOs also lack care coordination, which can lead to fragmented treatment, and navigating the network rules and claim processes can be confusing and time-consuming. Overall, while PPOs provide freedom of choice, that flexibility often comes at a higher financial and administrative burden.

Answered by Nathan Danovski on August 29, 2025

Broker Licensed in NC, GA, SC & TN, VA, WV & WY

Answered by Nathan Danovski Medicare Insurance Agent

Justin Call · Answer

In the Medicare world, everything is a give and a take.  If a carrier is going to give me a plan that includes out-of-network coverage, they usually will "take" something.  Such as having higher medical copays, or not as much of a dental benefit etc.

Also, the misunderstanding I see a lot regarding PPO's is that people think you have to have a PPO to be able to see a doctor in case of an emergency while traveling.  That is not true.  If it is a potential loss of life, limb, or illness and you have an HMO, you can go to the ER and be covered in-network.

Brianna Henward · Answer

PPO plans, which are medical plans that let you go outside of the network, can be great because they allow you to see most providers and see a specialist without a referral (though the specialist themselves often still requires the referral).

The disadvantages are that they typically are more expensive and have higher copays/deductibles than HMOs. Plus, even if your plan lets you go outside of the network, if your provider refuses to bill outside of their network then you'll be left with a messier reimbursement process vs simply being in-network. Lastly, many people pay for a PPO even when every doctor they'd like to see is actually in-network anyway. So they're paying more for worst coverage to gain a benefit they'll never use.

Rodney Turner · Answer

A PPO (Preferred Provider Organization) plan gives you flexibility, but there are a few disadvantages seniors should consider:

* Higher monthly premiums compared to many HMO plans
* Higher out-of-pocket costs like deductibles, copays, and coinsurance
* You may pay much more when using out-of-network doctors or hospitals
* Costs can be less predictable, especially if you need frequent care
* Some PPO Medicare Advantage plans may have higher maximum out-of-pocket limits than other plan types

Hank Ellis · Answer

Higer cost would be one of the main disadvantages. That would relate to premiums and out of pocket costs.

Kirk Doris · Answer

PPO programs are generally the most popular options among seniors electing to use Medicare Advantage plans. The PPO options allows the freedom to seek care from a provider not contracted with the host carrier at a higher cost to the subscriber. Generally the only disadvantage is a higher monthly premium for the plan along with elevated costs when seeking care from a non-contracted provider

Answered by Kirk Doris on August 25, 2025

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

Answered by Kirk Doris Medicare Insurance Agent

Andrew Zurbuch, MBA · Answer

If you're asking relating to Medicare Advantage & the network it uses. Then, not many disadvantages of a Preferred Provider Organization, PPO. I/We just have not had that many complaints over the years on Medicare Advantage, Preferred Provider Organization, PPO. I would say if a Medicare Beneficiary lives in a small City, then a disadvantage could be a lack of innetwork providers. Thank you.

Plans are insured or covered by a Medicare Advantage (HMO, PPO and PFFS) organization with a Medicare contract and/or a Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal with Medicare. We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

Priscilla Ramos · Answer

Disadvantages of a PPO include:

Higher premiums than HMO or Original Medicare alone
Out of network care can be very expensive
More complex billing and paperwork
Costs can add up quickly if you frequently see specialists or multiple providers

James Stang · Answer

I only represent UnitedHealthcare so I can only speak about our PPO plans. For 2026, our PPO plans seem to have higher premiums as well as higher costs for the benefits. The ability to see providers out of network usually is out weighed by the additional costs. 

My recommendation is to enroll in a HMO plan your provider accepts as opposed to a PPO, especially if it's your PCP that is out of network.

Don Golding · Answer

Like many things in life, there are advantages and disadvantages to the choices we make. In the case of Medicare PPOs v. Medicare HMOs, it depends on what is important to you. Generally speaking, PPOs allow you to self-refer to a specialist without the need to get a referral from your Primary Care Physician. You can also go outside your network and still receive covered care, although, in general, at a much higher cost share. PPOs usually have higher copays, coinsurances, and higher maximum out-of-pocket limits. It is best to consult an independent broker to compare all of your options and find a plan that fits your individual needs.

Answered by Don Golding on December 30, 2025

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

Answered by Don Golding Medicare Insurance Agent

Alan &quot;AL&quot; Minthorn · Answer

PPO plans have higher actuarial costs due to the clearly defined out of network benefits available.  Those higher costs are typically reflected in higher copays, coinsurances, and deductibles throughout the benefits; even a higher, or split MOOP.

For many individuals with either a HMO or HMO-POS plan - a national network of providers may be available without the PPO burden to the financial structure of the plan. As long as you stay in the national network of providers you have "local" cost sharing. 

Having a provider strategy at both "ends" for snowbirds is the smart thing to do. All plans are required to cover emergency care as in-network.

Steve Schnell · Answer

You might have a premium. Also, you still have network restrictions to avoid out of network services.

Diane Poythress · Answer

There is no easy way to answer this question.

Why are you choosing to go with Medicare Advantage over original Medicare?  If you need to go to a center of excellence, i.e., Mayo Clinic, then a Medicare supplement is your only option. If you travel and need to see doctors outside your network, either Original Medicare or a PPO will work for you.

Both original Medicare and the Medicare Advantage PPO plan allow you to see doctors out of “next work”. The PPO includes additional benefits of the Advantage plans, such as dental and vision. Many Medicare Advantage PPO plans have low or no monthly premiums. With the PPO plan, you typically may have higher copays and a higher max out-of-pocket when you choose to go out of network.  

 With Original Medicare, you can choose any doctor who accepts Medicare. However, you have copays and deductibles with Original Medicare. Now, most people choose a Medicare supplement to cover the copays and deductibles that original Medicare does not cover. They also need to enroll in Part D for prescriptions. Original Medicare also doesn’t cover dental or vision.  If you need dental and vision, you will need to enroll in a plan. 

Unless you have planned for retirement and set aside:
•	Part B monthly premium 2026 $202
•	Medicare supplement monthly premium average cost Plan G $160 + first $283 of Medicare costs
•	Medicare supplement monthly premium average cost Plan N $130 first $283 of Medicare costs and $20-50 copays for doctor and emergency room visits.
•	Prescription plan monthly premium estimate $0-$50 + cost of prescriptions

I guide my clients with probing questions and walk through the numbers to determine whether it is more advantageous for them to choose a Medicare Advantage PPO plan or to remain with Original Medicare and add a supplement, Part D, and vision and dental coverage.

Biltmore Health Insurance
Diane Poythress
Contact us

Dawn Young · Answer

Hi,

PPO’s are great. You have the freedom to visit any doctor that accepts Medicare. The down side would be going out of network means you have a higher out of pocket cost. 

Hope this helps. Please reach out if you need additional help. 

Dawn Young
HealthMarkets Insurance Agency

April Cintron · Answer

You’ll  pay higher monthly premiums and out-of-pocket costs than with HMO plans.
You have more responsibility for managing and coordinating your own care without a primary care doctor.

David Treadway · Answer

The disadvantage of a PPO is that it is an advantage plan and subject to change each and every year. Advantage plans are 1 year contracts that run Jan 1 - Dec 31. The plans change each year and some non-renew, meaning discontinue altogether. They also require prior authorization and the use of networks or acceptance by a provider outside of the network.  Supplements don't do that. Those would be disadvantages. 

On the flipside there are many advantages to a PPO including a low premium and the ability to go outside of a defined network. They also typically include coverage for RX, vision, dental and more; however, you asked for the disadvantages so I'll leave it at that. I hope this was helpful to you and others.

Robert Jones · Answer

PPOs actually give you a lot of flexibility regarding providers. However, you would want to make sure your current doctors are in network to minimize out-of-pocket costs.

Please contact if you wish to discuss - Bob Jones -
Thank you
Bob

Glenn Quinn · Answer

PPO health insurance plans, while offering flexibility in choosing providers, have several disadvantages. These include higher monthly premiums, potential for higher out-of-pocket costs, and the possibility of increased paperwork. Additionally, PPOs may lead to fragmented care due to the lack of strong coordination between providers.

Answered by Glenn Quinn on June 29, 2025

Broker Licensed in FL, AL, AR & 13 other states

Answered by Glenn Quinn Medicare Insurance Agent

Fred Manas · Answer

While PPO plans offer flexibility, they have several disadvantages to consider: 
Higher Costs: PPO plans generally have higher monthly premiums and out-of-pocket costs compared to other types of health plans like HMOs. This is because you pay for the wider network of providers and the freedom to see specialists without referrals.
Deductibles: You often have to meet an annual deductible before your health insurer starts covering medical costs.
Fragmented Care: Since you don't need a primary care physician (PCP) to coordinate your care and referrals to specialists, there's less oversight and potential for a less coordinated approach to your treatment.
Paperwork: If you choose to go outside your PPO network, you may be responsible for filing claims yourself, which can be a time-consuming and confusing process.
Out-of-Network Expenses: While PPOs offer some coverage for out-of-network providers, you'll still have to pay more out of pocket for these services compared to in-network care.
Limited Ability to Control Healthcare Costs: PPOs are becoming less effective at controlling rising healthcare costs due to factors like fragmented care, lack of provider coordination, and increased bargaining power of healthcare providers.

Vachik Chakhbazian · Answer

while offering flexibility in provider choice, have several disadvantages. These include higher monthly premiums, potentially higher out-of-pocket costs, and the risk of fragmented care due to less coordination between providers.

Answered by Vachik Chakhbazian on June 30, 2025

Agent Licensed in CA, AL, AR & 22 other states

Answered by Vachik Chakhbazian Medicare Insurance Agent

Mary Brown · Answer

A PPO gives you more flexibility to see doctors both in and out of network without referrals. The downside is that premiums and out-of-pocket costs are usually higher, especially if you go out of network, so it’s important to review the potential costs carefully with a local Medicare agent.

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

The disadvantages of an Advantage PPO are the high co-pays, as compared to the HMO's. Also, the extra benefits - dental, vision, hearing, etc - are much less as compared to HMO's. The only advantage, as compared to an HMO is that you don't need a referral to see a specialist. But there are United Healthcare HMO-POS plans in varying areas that have the fairly low co-pays of an HMO, but don't need a referral for a specialist. See if one of these is in your area.

Answered by Andrew Kramer on August 18, 2025

Agent Licensed in FL

Answered by Andrew Kramer Medicare Insurance Agent

Carol Thompson · Answer

The disadvantages of a PPO: usually you have to pay the full amount of of Part B, higher co-pays and higher co-insurance. You are paying for the convenience or freedom so see more doctors without an referral from the primary care doctor.

Answered by Carol Thompson on October 8, 2025

Broker Licensed in FL, LA, MI & NC, SC, VA & WI

Answered by Carol Thompson Medicare Insurance Agent

Todd Bostic · Answer

The biggest problem with a PPO is cost for seeing a doctor out of network cost. What I mean is that cost is more expensive than in network cost more than in network cost and your benefits would be less than HMO.

Answered by Todd Bostic on September 22, 2025

Broker Licensed in TX, AL, AZ & 12 other states

Answered by Todd Bostic Medicare Insurance Agent

Dean Chiapetto · Answer

The disadvantage of the PPO is that your expenses can be higher than a HMO or Original Medicare and a supplement. Check with your Local Broker.
Brokers Make a Difference!

Pat Papson · Answer

Goodmorning 

Thanks for your question.

As an Agent and a over 65 person, I find no disadvantages in a PPO, you have lots of flexibility as to choice of Doctors. 

Where as HIMOs have more restrictive rules..

Hope this information was helpful.

Eizel Mere · Answer

There are adcantages and disadvantages to every Medicare Advantage plan. For people that have a lot of specialist and are unable to find a plan who thwy all take a PPO is better. The disadvantages are higher copays and lower benefits. The high copays can be covered with a hospital indemnity plan so you buuld yourself better coverage for a lower price than a Supplement. Let me know if I can assist you with anything.

Answered by Eizel Mere on October 20, 2025

Broker Licensed in FL

Answered by Eizel Mere Medicare Insurance Agent

Jeffrey Sodikoff · Answer

THE ONLY DISADVANTAGE IS THAT YOU STILL WANT TO MAKE SURE ALL YOUR CARE IS IN NETWORK BECAUSE THE OUT-OF-NETWORK BENEFITS ARE VERY EXPENSIVE. YOU DO NOT NEED REFERRALS BECAUSE IT IS NOT AN HMO. MANY PPO PLANS HAVE NATIONWIDE NETWORK,S UNLIKE AN HMO

Answered by Jeffrey Sodikoff on November 19, 2025

Agent Licensed in FL

Answered by Jeffrey Sodikoff Medicare Insurance Agent

James Wareheim · Answer

There are some disadvantages with a PPO.  One, you would need to stay in network for the lowest out of pocket cost for care.  The second is the plans can change year to year.  With a Medicare Supplement your coverage is locked in, although your rates could change.  Also with a Medicare Supplement you would want to have a Prescription Drug Plan.  That coverage and cost can change year to year.

The advantage of the PPO is it has a low to $0 premium and includes your prescription coverage.  They usually have extra benefits such as Silver Sneakers.  

It comes down to personal needs, and wants.

Patricia Graham · Answer

I don't know of a disadvantage besides the fact that it may cost more than a zero premium HMO but you have less consumer control and total reliability on the company to decide about your health care needs on a hmo

Answered by Patricia Graham on September 14, 2025

Agent Licensed in WA

Answered by Patricia Graham Medicare Insurance Agent

Chauncey Bragg · Answer

The main disadvantages of PPO plans are that they tend to have higher monthly premiums, higher out-of-pocket costs, less predictability, and more cost-sharing complexity.

Daniel Matar · Answer

PPO plans can have higher premiums and out of pocket costs associated with copays and coinsurance. Since no PCP is required, care could be less coordinated as well.

Seyed Kamarei · Answer

The main PPO disadvantages include higher premiums and out-of-pocket costs compared to HMOs, fragmented care with poor provider coordination leading to duplicate testing, limited bargaining power against consolidated health systems that negotiate higher rates, increased costs from out-of-network patient choices, ...Jan

Answered by Seyed Kamarei on February 9, 2026

Agent Licensed in IL

Answered by Seyed Kamarei Medicare Insurance Agent

Elijah Ridley · Answer

The major disadvantage of a PPO are the out of pocket costs when you are out of network. While it's great to be able to go to doctors or specialists outside of your network, you must understand that you're not subject to the copays that you're used to but a coinsurance amount. So make sure you understand the costs associated with going out of network.

Answered by Elijah Ridley on November 14, 2025

Broker Licensed in TN

Answered by Elijah Ridley Medicare Insurance Agent

Al Bernotas · Answer

Copays, coinsurance, deductibles, and MOOP (Maximum Out Of Pocket) are generally higher with a PPO compared to an HMO.  You are still working within the confines of a network of providers.

Rhonda Byers · Answer

Doctor and Hospital networks.
The doctor being able to pull out of network at anytime.
That the insurance is county specific, keeping travel to a min.

What are disadvantages of PPO?

Agents: Share Your Expertise

Seniors: Ask a Question of Your Own

Related Questions

Agent Locator

Medicare Agents Hub
A non-government resource website

What are disadvantages of PPO?

Agents: Share Your Expertise

Seniors: Ask a Question of Your Own

Related Questions

Agent Locator

Medicare Agents HubA non-government resource website

Medicare Agents Hub
A non-government resource website