Medicare HMO Plans vs. Medicare PPO Plans: What is the Difference?

Medicare Advantage plans are a type of umbrella plan that combines hospital, medical and prescription coverage through a private insurance company. These plans are similar to traditional insurance as they operate off of a network like an HMO or PPO. The biggest difference between the two being provider flexibility, among other things.

Medicare Advantage HMO plans offer some of the following features:

• Must choose a primary care physician.
• Must use in-network providers for covered services.
• Most plans require a referral to see an in-network specialist.

With an HMO you typically must use network providers unless it is an emergency or urgent situation. Some carriers have forgone the referral aspect of a traditional HMO, so you may be able to see specialists without one depending on the plan you have. HMO plans typically have lower copays and out of pocket maximums.

Medicare Advantage PPO plans offer some of the following features:

• Many plans do not require you to choose a primary care physician.
• Offer coverage for in-network and out-of-network providers (may pay more for out-of-network)
• Most plans do not require a referral to see a specialist.

With a PPO you may use in and out-of-network providers, however when you see an out-of-network provider you must make sure they are willing to accept the plan. Unless it is an emergency or urgent situation, non-contracted providers can deny care. With a PPO plan, copays and out of pocket maximums may be higher when you see out-of-network providers.

As you can see, there are key differences between Medicare HMO plans and Medicare PPO plans. Remember—everyone’s needs are different, and you are the best judge of which coverage would work best for you.

If you have any questions, please call AMAC’s Medicare Advisory Service to speak to one of our trusted, licensed insurance advisors!

Call 1-800-334-9330 or Get Quote