What’s the Difference between Medicare HMO and Medicare PPO Plans?Posted by Medicare Made Clear
Medicare HMO plans and Medicare PPO plans are two different types of Medicare Advantage plans. Medicare Advantage plans are an alternative to Original Medicare (Parts A and B). Plan members are still in the Medicare program, but their benefits are provided through a Medicare-approved private insurance company instead of through the government.
Many people wonder how Medicare HMO plans and Medicare PPO plans compare. The table below shows the key differences and similarities. The differences are mostly related to provider choice and how that may affect out-of-pocket Medicare costs. But plans vary, so it’s important to review plan details carefully.
Medicare HMO and Medicare PPO Plan Comparison Table
|Plan Feature||Medicare HMO||Medicare PPO|
|Has a contracted network of doctors and hospitals||Yes||Yes|
|Must choose primary care provider from plan network||Yes||No|
|Must use providers within the plan network for covered services||Yes
(except for Point-of-Service plans)
(may pay more out of network)
|Referral required to see a specialist||Varies by plan||No|
|May include drug coverage||Yes||Yes|
|Covers emergency care received from any provider||Yes||Yes|
Medicare PPO plans offer the freedom to see any provider you choose, even though they have provider networks. You may get covered services from providers outside the network who accept Medicare, but you may pay more.
Medicare HMO plans cover health care services provided within a network of contracted providers. These plans may not cover out-of-network services at all. You could end up footing the entire bill for these services, depending on the specific plan.
Both Medicare HMO plans and Medicare PPO plans – like all Medicare Advantage plans – combine hospital insurance and medical insurance in a single plan. And both cover emergency care no matter where it’s received.
Many Medicare HMO plans and Medicare PPO plans offer prescription drug coverage and other benefits not provided by Original Medicare, such as coverage for routine dental and vision care.
More about Medicare HMO Plans
“HMO” is short for Health Maintenance Organization. Medicare HMOs operate much the same as other HMO plans. Many people have HMO plans through their employers, for example.
Medicare HMO plan members must choose a primary care provider (PCP) who is in the plan network. Your PCP provides ongoing care and helps you get the services you need.
PCPs also provide referrals to specialists like cardiologists or dermatologists, when needed. Specialist or other services received without a referral may not be covered. You could be responsible for the entire cost.
You usually pay only a co-payment for health care services received from network providers, after any deductible is met. Plans may also charge a monthly premium.
More about Medicare PPO Plans
“PPO” is short for Preferred Provider Organization. In general, Medicare PPOs offer plan members more choices than HMOs do.
Medicare PPO plan members may choose to see any provider they want to. They are not required to have a PCP to coordinate their care or to make referrals.
Medicare PPO plans do have provider networks, however, and members pay less when they use network providers. Plans may have a deductible and they usually charge a monthly premium.
Provider choice and out-of-pocket costs are two important issues for many people when choosing Medicare coverage. You may need to decide which of these issues is more important to you if you are choosing between a Medicare HMO plan and a Medicare PPO plan. Make sure to review and compare plan details before choosing a Medicare plan.
For more information, explore MedicareMadeClear.com or contact the Medicare helpline 24 hours a day, seven days a week at 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048.