Medicare Advantage HMO vs PPO Plans: Which Provides Better Coverage for Doctor Visits?

Mike Olmos by Mike Olmos | Licensed since 2010
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This article was updated on: 10/06/2018

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HMO vs PPO…that’s what you may be wondering if you’re looking at Medicare Advantage plans. We’ll talk about these types of Medicare Advantage plans and why you might prefer one type over the other.

What are Medicare Advantage HMO vs. PPO plans?

There are multiple types of Medicare Advantage plans. Two popular plan types are Health Maintenance Organization (HMO) plans and Preferred Provider Organization (PPO)* plans.

Medicare Advantage HMO vs. PPO plans: what do they have in common?

  • Private insurance companies contracted with Medicare offer Medicare Advantage HMO and PPO plans under the Medicare Advantage (Medicare Part C) program.
  • Many Medicare Advantage HMO and PPO plans provide additional benefits, such as Medicare Part D prescription drug coverage, routine vision, and dental coverage.
  • Medicare Advantage HMO and PPO plans generally have networks of participating hospitals and doctors that plan members use to receive full benefits for covered services, such as doctor visits.
  • Like all plans under Medicare Part C, Medicare Advantage HMO and PPO plans limit the amount you pay out-of-pocket during the year for covered services. If your out-of-pocket costs for covered services reaches a certain limit, the plan generally pays for any further covered medical care for the rest of the year.

Medicare Advantage HMO vs. PPO plans: how are they different?

When you’re weighing Medicare Advantage HMO vs. PPO plans, it’s important to know the differences, especially since they’re similar in many ways.

Medicare Advantage HMO plans typically give you access to a network of participating doctors and hospitals. Generally, you must use providers in the HMO plan’s network. An HMO plan might cover out-of-network services such as:

  • Emergency care
  • Urgent care or dialysis treatment when you are temporarily traveling outside the HMO’s service area

Many Medicare Advantage HMO plans emphasize care coordination. You must select a primary care physician (PCP) within the plan’s network to provide your routine care and order other treatments. You may need a PCP referral to receive coverage for specialist’s services, special tests and therapies, or medical supplies.

Medicare Advantage HMO plans typically have lower monthly premiums and cost-sharing, such as deductibles, copayments, and coinsurance, than Medicare Advantage PPO plans.

In contrast, Medicare Advantage PPO plans may provide more flexibility in choice of providers than HMO plans. Generally, PPOs let you use doctors outside the plan network, although it might cost you more. You usually don’t have to select a PCP or get a referral to see a specialist.

Medicare Advantage HMO vs. Medicare Advantage PPO – How do you choose?

If you have a choice between Medicare Advantage HMO vs. PPO plans, consider your medical needs, your health-care preferences, and your budget.

  • Take a look at the doctors and hospitals in the Medicare Advantage HMO network. Usually, you can read about individual doctors on the plan’s website. If you’re satisfied with what you see, you might want to choose the HMO plan.
  • Do you like your primary care doctor to coordinate all of your care? If so, a Medicare Advantage HMO plan may be a good option for you.
  • Do you have a long-standing, satisfactory relationship with a doctor who isn’t in a Medicare Advantage HMO plan’s network in your area? If you want to stay with that doctor, a PPO plan might be a good choice for you. Make sure the doctor accepts Medicare assignment.
  • Do you like being able to see the specialist of your choice without getting a referral? A PPO plan may appeal to you.

You may pay slightly more for Medicare Advantage PPO coverage than HMO coverage. Only you can decide whether the flexibility is worth the cost. Remember, if you decide on a PPO plan, make sure any health-care provider you visit accepts Medicare assignment, or you might have to pay even more for the visit.

Are you looking for more information about Medicare Advantage HMOs vs PPOs? Would you like to learn more about Medicare coverage options where you live? Please feel free to contact me by using the links below. If you wish to compare some of the Medicare plans where you live, use the Compare Plans button on this page.

Benefits, premiums and/or copayments/co-insurance may change on January 1 of each year.
The provider network may change at any time. You will receive notice when necessary.

Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

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