Plans & Coverage

Medicare PPO Plans

A PPO (Preferred Provider Organization) is a Medicare Advantage plan that lets you see out-of-network providers at a higher cost and usually skips referrals entirely. PPOs suit people who travel, split time between states, or want flexibility while still getting Advantage extras. You continue paying the $202.90 Part B premium in 2026.

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How a PPO differs from an HMO

	PPO	HMO
Out-of-network care	Covered at a higher cost share	Generally not covered
Referrals	Usually not required	Usually required
Premium	Typically higher	Typically lower
Out-of-pocket maximum	Often two — in-network and combined	One
Best for	Travellers, out-of-area specialists	Settled local care

The two out-of-pocket maximums

This is the detail most people miss. A PPO usually has an in-network maximum and a higher combined maximum that includes out-of-network spending. If you use out-of-network providers regularly, the number that actually protects you is the combined one.

Compare both when you shop, not just the advertised figure. General cost rules are on Medicare.gov.

Who a PPO suits

You winter outside New Mexico or travel for months at a time.
You see a specialist in another state or another metro area.
You want to self-refer rather than route everything through a primary care doctor.
You want Advantage extras but not an HMO's network limits.
You'd rather pay a bit more monthly for flexibility.

What a PPO still can't do

A PPO is not Medigap. Out-of-network providers can decline to see you, cost sharing out of network is meaningfully higher, and prior authorization still applies to many services. If you want genuinely unrestricted access to any provider who accepts Medicare, that's Medigap plus a Part D plan, not a PPO.

Costs to plan for in 2026

Part B premium — $202.90 a month for most people (CMS 2026 fact sheet), more with IRMAA.
Plan premium — varies; PPOs typically charge more than HMOs.
Copays and coinsurance — lower in network, higher out.
The in-network and combined out-of-pocket maximums.

Changing plans later

You may change during October 15 – December 7 for a January 1 start, and Advantage members get one switch during January 1 – March 31. Plan availability, networks, and premiums all reset annually — see Medicare.gov for the current rules.

Not sure which of these fits you? A free 15-minute call with a licensed local advisor sorts it out — no pressure, and no cost to you. We do not offer every plan available in your area. For a complete list of every plan in your county, use Medicare Plan Compare or call 1-800-MEDICARE.

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Questions, answered

Do I need referrals on a Medicare PPO?

Usually not — self-referral to specialists is one of the main reasons people choose a PPO. Prior authorization for certain procedures can still apply.

Is out-of-network care really covered?

Yes, but at a higher cost share, and the provider must be willing to bill the plan. Check the combined out-of-pocket maximum, because that's the ceiling that applies when you use out-of-network care.

Are PPOs available across New Mexico?

Availability varies by county and changes every year, and rural counties typically have fewer options than the Albuquerque metro. We check what's actually offered in your ZIP.

PPO or Medigap if I travel a lot?

Both work for travel, differently. A PPO covers out-of-network care at a higher cost within a plan structure; Medigap has no network at all and works with any provider who accepts Medicare, but costs more monthly and needs a separate drug plan.

Sources

Figures are for 2026 and come from the official sources above. Plan-specific costs vary by county and carrier — confirm yours on Medicare Plan Compare or with a licensed agent.

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