Definition. A PPO is a type of Medicare Advantage plan with a network of doctors and hospitals that also covers care from out-of-network providers who accept Medicare, usually at a higher cost to you. You generally don't need a referral to see a specialist.
What it means
Compared with an HMO, a Medicare Advantage PPO generally:
- Covers out-of-network care, usually with higher copays or coinsurance.
- Doesn't require you to choose a primary care doctor.
- Doesn't require referrals for specialists.
- Has two out-of-pocket limits: one for in-network care and one for in- and out-of-network care combined.
Like every Medicare Advantage plan, a PPO covers everything Original Medicare covers, and emergency and urgently needed care are covered anywhere in the U.S. Medicare Advantage plans may offer extra benefits such as dental, vision, hearing or fitness. Extra benefits vary by plan and county, may have limits and costs, and not every plan offers them. Check a plan's Summary of Benefits or Evidence of Coverage.
In Oregon
Out-of-network coverage can matter if you live in a rural county, spend part of the year outside Oregon or travel to see specialists. Plan types differ by county, and five Oregon counties have no Medicare Advantage plan open to everyone for 2027. Check your county's page, read about rural Oregon and Medicare, or request a call from a licensed insurance agent.
Sources
- Medicare.gov — Types of Medicare Advantage plans
- Medicare.gov — Compare Original Medicare and Medicare Advantage
Frequently asked questions
Are out-of-network costs in a PPO predictable?
Less so than in-network costs. Plans often use coinsurance rather than flat copays for out-of-network care. Check the plan's Evidence of Coverage, and confirm a provider will see you before you go.
Does a PPO have an out-of-pocket maximum?
Yes. Medicare Advantage PPOs have an in-network limit and a combined in- and out-of-network limit. For 2026, Medicare's caps are $9,250 in-network and $13,900 combined; each plan sets its own amounts within them.
Medicare in your Oregon county
Plans, local agents and help, county by county: Multnomah · Washington · Clackamas · Lane · Marion · Jackson · Deschutes · Linn · Douglas · Yamhill · Benton · Polk · Josephine · Umatilla · Klamath · Coos · Columbia · Lincoln · Clatsop · Malheur · All 36 counties →
