A Medicare Advantage HMO generally requires you to use its network and get a referral from your primary care doctor before seeing a specialist. A PPO lets you use out-of-network providers for covered services at a higher cost, usually without referrals. The right choice depends on where your doctors practice and how you travel.
How a Medicare Advantage HMO works
Medicare says an HMO generally covers care only from providers in the plan's network. The exceptions are emergencies, urgent care, and out-of-area dialysis. Most HMOs also require a referral from your primary care doctor before you see a specialist.
Some HMOs are point-of-service plans (HMOPOS). Those cover certain out-of-network care, but usually at a higher copayment or coinsurance.
How a Medicare Advantage PPO works
A PPO has a network too, but you can also use out-of-network providers for covered services. You usually pay more for that care, and the provider has to agree to treat you and not have opted out of Medicare. Referrals are generally not required.
That flexibility is the main reason people choose a PPO. A PPO still has a network, so a doctor outside it can cost you more or decline to see you.
What an HMO and a PPO have in common
- Both provide your Part A and Part B benefits through a private insurer approved by Medicare.
- Both can require prior authorization before certain services are covered.
- Both set an annual limit on what you pay out of pocket for covered services.
- Both change from year to year. Networks, drug lists, and copays can look different on January 1 than they did last December.
Five questions to answer before you choose
- Is each of your doctors and your hospital in the network today? Call the office and ask. A printed directory can be out of date.
- Do you see specialists often? If so, ask whether each visit needs a referral and who has to approve it.
- What does an out-of-network visit cost, and is it covered at all? The answer differs between an HMO, an HMOPOS, and a PPO.
- Are your prescriptions on the plan's drug list, and at what cost tier?
- Where do you spend time away from home? If part of your year is in Arizona or Nevada, ask how the plan treats non-emergency care outside its service area.
How Luis compares them for you
Luis Alvarenga is an independent agent, so he is not tied to one carrier's HMO or PPO. He lines up the plans he offers in your county against your doctors and your prescriptions, and he replies to every request within 24 hours. He does not offer every plan available in your area, so he points you to Medicare.gov and your local SHIP for the full list.
The Medicare Advantage plans he offers are in California, Arizona, and Nevada. See the Medicare Advantage page for the service area.
Frequently asked questions
Can I see any doctor with a Medicare Advantage PPO?
No. A PPO has a network, and out-of-network providers have to agree to treat you and not have opted out of Medicare. You usually pay more for out-of-network care.
Do Medicare Advantage HMOs require referrals?
Most HMOs require a referral from your primary care doctor before you see a specialist. Referral rules differ by plan, so check the plan documents for each specialist you use.
Can I switch from an HMO to a PPO?
During the Annual Enrollment Period, October 15 to December 7, you can switch to a different Medicare Advantage plan effective January 1. If you are already in a Medicare Advantage plan, you also get one change between January 1 and March 31.
Is a PPO always more expensive than an HMO?
No. Premiums, copays, and the out-of-pocket limit vary by plan. Compare the total cost for your own doctor visits and prescriptions instead of assuming from the plan type.