What are disadvantages of PPO?

Question

Norman Smith · Accepted 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

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

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.

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Edward Smith, ChFC, CRPS, AIF · 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 & SC

Answered by Edward Smith, ChFC, CRPS, AIF 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

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

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.

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

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.

What are disadvantages of PPO?

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What are disadvantages of PPO?

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A non-government resource website