Medicare Advantage HMO vs. PPO.
The two most common Medicare Advantage plan types. Network rules, referrals, costs — here is what changes between them.
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HMO basics
HMO plans require you to use the plan's network and usually require a referral from a primary care physician to see a specialist. Out-of-network care is generally not covered except for emergencies.
- Usually lower premiums than PPOs
- Lower copays at in-network providers
- Tighter network — more restrictive
- Often requires a primary care doctor (PCP)
PPO basics
PPO plans let you go out of network at higher cost. No referral usually required to see a specialist.
- Higher premiums than HMOs
- More flexibility — see specialists directly
- Out-of-network coverage at higher copay/coinsurance
- Wider provider networks
Which fits which person
HMO fits people who: have a steady PCP relationship, want lower premiums, do not travel often, and are happy with the plan's network.
PPO fits people who: want flexibility, travel between states, have specialists in different systems, and can afford a higher premium for that flexibility.
See our Medicare Advantage overview for the full structural picture.