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Understanding Medicare PPO Plans in 2026: A Comprehensive Guide

Navigating Medicare can feel overwhelming — especially when you’re faced with multiple plan types and ever-changing policies. One option that continues to resonate with many beneficiaries is the Medicare Advantage PPO (Preferred Provider Organization) plan. In 2026, there are significant trends, changes, and trade-offs worth understanding. This guide breaks it all down.

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A Purely Educational Overview of Key 2026 Changes Published by Policy Engineer Insurance Solutions — For Informational Purposes Only  At Policy Engineer Insurance Solutions, our goal is to help you understand these changes from an educational standpoint so you can plan with clarity.

1. What Is a Medicare PPO Plan?

  • Medicare Advantage (Part C): PPO plans are a type of Medicare Advantage plan. These are private insurer-run plans that bundle Medicare Part A (hospital) and Part B (medical), and often Part D (prescription drugs).

  • Flexibility: Unlike HMO (Health Maintenance Organization) plans, PPOs typically allow you to see both in-network and out-of-network providers. You don’t always need referrals to see a specialist. This gives more freedom, but it may come at a higher cost when using out-of-network providers.

  • Cost Structure: Costs may include monthly premiums, co-pays, or coinsurance for services, and in some cases, out-of-pocket maximums. The exact terms vary by plan.

Review Your Medicare Plan

2. What’s Changing for Medicare PPOs in 2026?

There are several key shifts in the Medicare Advantage (MA) market relevant to PPO plans in 2026. These influence cost, availability, and program design.

a) Overall Stability with Some Premium Declines
CMS projects that average Medicare Advantage premiums will decrease slightly in 2026.

  • The projected average monthly premium for MA across all types (including PPOs) is estimated to drop from $16.40 in 2025 to $14.00 in 2026.

  • This suggests that, for many beneficiaries, Medicare Advantage remains a cost-competitive alternative.

b) Policy & Technical Updates
New rulemaking and policy adjustments are being implemented for 2026:

  • CMS’s 2026 final rule for Medicare Advantage includes updates related to Part D, Star Ratings, and how supplemental benefits are structured.

  • These changes may affect coverage, network design, and out-of-pocket responsibilities.

c) PPO Plan Reductions
The Medicare Advantage landscape is evolving:

  • According to industry analysis, PPO offerings are shrinking, with more PPO plans being phased out compared to HMOs. 

  • Specifically, many of the discontinued PPOs are “$0-premium” PPO MA-PD plans, reducing options for beneficiaries seeking low-premium PPOs.

  • Insurers may be cutting these PPOs due to cost risk: Wide provider networks make it harder to control expenses compared to tighter HMO networks. 

d) Quality Ratings Still Matter

  • CMS assigns Star Ratings to Medicare Advantage plans based on quality measures (e.g., access to care, patient satisfaction, management of chronic conditions). (CMS)

  • These ratings affect both beneficiary decision-making and how much insurers are paid. In 2026, these quality ratings continue to play a significant role.

e) Cost-Sharing Adjustments for Dual-Eligible PPOs

  • Proposed changes include limits on out-of-network cost sharing for PPOs designed for dual-eligible individuals (those eligible for both Medicare and Medicaid). (CMS)

  • These adjustments aim to make PPOs safer and more predictable for vulnerable populations.

f) Plan Exit Risk

  • Some major insurers are pulling back on PPO offerings; for example, reports indicate that UnitedHealth will discontinue over 100 Medicare Advantage plans by 2026, including many PPOs. 

  • For beneficiaries, this means potential disruption: if your PPO is discontinued, you may need to choose a new plan or switch to another type. of plan

3. Pros and Cons of Choosing a PPO in 2026

Advantages:

  1. Provider Flexibility: Ability to see out-of-network doctors.

  2. No Referral Needed: In many PPO plans, you can see specialists without a referral.

  3. Predictable Upper Costs: Many PPOs have an annual maximum out-of-pocket limit, helping protect against very high costs.

  4. Suitable for Travelers: If you split time between places (e.g., “snowbirds”), a PPO’s flexibility can be beneficial.

Disadvantages:

  1. Fewer Options: With fewer PPO plans, your local choices may be more limited.

  2. Potential for Higher Costs: Using out-of-network providers generally results in higher costs.

  3. Financial Risk for Insurers: Because of this risk, some insurers are reducing or discontinuing PPOs, which may lead to less competition.

  4. Plan Complexity: Each PPO plan’s structure (premium, co-pays, out-of-pocket max, drug coverage) can vary widely, so it’s critical to compare carefully.

4. Real-World Examples: What Some PPOs Look Like in 2026

  • Johns Hopkins Advantage MD – 2026 PPO:

    • $95/month premium

    • No medical deductible

    • $5 PCP copay, $45 specialist copay

    • Telehealth is $0 copay in-network. Johns Hopkins Advantage MD

  • Johns Hopkins Advantage MD – 2026 “Plus” PPO:

    • $155/month premium

    • No medical deductible

    • $0 copay for primary care, $40 for specialists

    • Emergency copay: $110 (waived if hospitalized) Johns Hopkins Advantage MD

  • Blue Medicare Advantage Valor PPO:

    • Their 2026 Annual Notice of Change shows adjustments in various cost-sharing categories (e.g., skilled nursing facility copay differences, in- vs out-of-network) that beneficiaries must carefully review. digital-assets.wellmark

Questions?

5. Should You Choose a PPO Plan in 2026?

Here are some guiding questions to help you decide:

  1. Are your preferred doctors in-network?
    Even though PPOs allow out-of-network visits, staying in-network is usually cheaper.

  2. Do you travel or split time between locations?
    If you’re not always in one place, PPO flexibility may save you in the long run.

  3. How much care do you expect to use?
    If you see specialists often or need more complex care, PPOs might offer better access. But if most of your care is routine, a tighter HMO could be more cost-effective.

  4. What is your risk tolerance?
    Consider worst-case scenarios for out-of-pocket costs. Check the maximum out-of-pocket in your plan.

  5. Have you checked the plan’s 2026 changes?
    Look at each plan’s Annual Notice of Change (ANOC) for 2026. Insurer changes, cost-sharing, network updates, and benefit tweaks can significantly affect your year-to-year costs.

  6. How do the quality ratings look?
    Use CMS’s Star Ratings when comparing plans — higher-rated plans may provide better value or care.

 

Review Your Strategy

6. Tips for the 2026 Enrollment Period

  • Use Medicare Plan Finder: By October 1, 2025, the tool should reflect 2026 plan options. CMS

  • Review Notices: Carefully read the Annual Notice of Change from your plan(s).

  • Ask for Help: Call 1-800-MEDICARE or work with a licensed agent who understands Medicare Advantage.

  • Compare Total Cost, not just premium: Include premiums, copays, coinsurance, and the worst-case out-of-pocket.

  • Consider Long-Term Needs: If your health needs may change, consider whether network flexibility or a lower out-of-pocket risk is more important to you.

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