Medicare HMO vs. PPO:
What’s best for you?
Medicare Advantage (Part C) plans are an excellent option for people who want an all-in-one plan that offers more coverage than Original Medicare (Parts A and B). The two main types of Advantage plans, Medicare HMO and PPO plans.
Having these options allows you to choose the type of Medicare Advantage plan that best fits your priorities based on two key factors: cost and flexibility to see the doctors of your choice.
What is an HMO and PPO?
HMO
HMO (Health Maintenance Organization) plans typically have lower out-of-pocket costs but require you to choose care within the plan’s network.
PPO
PPO (Preferred Provider Organization) plans may have higher premiums and copays but offer greater flexibility to see a wider range of health care providers.
Provider Networks: What You Need to Know
A network is the specific list of doctors, hospitals, and other health care providers contracted by a Medicare Advantage insurance company to ensure lower negotiated rates. A plan’s network can be determined by both geography and preferred providers.
Understanding a plan’s network is important to ensure that you get the coverage you need. If you’re unsure, you can visit a plan’s website to check if a particular doctor or facility is in their network. See if your current doctors are part of the Blue Cross Blue Shield of Massachusetts network.
Medicare HMO vs. PPO: The Key Differences
HMO | |
---|---|
Out-of-pocket costs | Often have no or lower monthly premiums and lower out-of-pocket costs. |
Flexibility to get health care where I want | Must get health care from providers and facilities within the plan’s network, except in emergencies. |
Need for a primary care physician | Need a primary care doctor within the plan’s network of approved providers. |
Specialty care referrals | Need a referral for most specialty care, such as a cardiologist. |
PPO | |
Out-of-pocket costs | Monthly premium, if there is one, and out-of-pocket costs are generally higher. |
Flexibility to get health care where I want | Can choose out-of-network hospitals and doctors, but they may cost more. |
Need for a primary care physician | Can choose any doctor that takes Medicare. |
Specialty care referrals | Don’t need a referral for specialty care. |
HMO | PPO | |
---|---|---|
Out-of-pocket costs | Often have no or lower monthly premiums and lower out-of-pocket costs. | Monthly premium, if there is one, and out-of-pocket costs are generally higher. |
Flexibility to get health care where I want | Must get health care from providers and facilities within the plan’s network, except in emergencies. | Can choose out-of-network hospitals and doctors, but they may cost more. |
Need for a primary care physician | Need a primary care doctor within the plan’s network of approved providers. | Can choose any doctor that takes Medicare. |
Specialty care referrals | Need a referral for most specialty care, such as a cardiologist. | Don’t need a referral for specialty care. |
In addition to basic health care coverage, both HMO and PPO plans are Medicare Advantage plans, so they are likely to offer a range of additional benefits, such as prescription drug benefits, vision, dental and hearing coverage, and more.
Medicare HMO vs. PPO: What to Consider
Here are four questions to ask yourself when choosing between a Medicare HMO and PPO Plan:
A Medicare HMO-POS Plan Offers a Combination of Benefits
Another option is a Point of Service (POS) plan, which combines the benefits of a Medicare PPO and HMO plan.
Can see doctors and hospitals outside of the plan’s network (for some services), but deductibles and copays may be higher
Still need a primary care doctor within the plan’s network
May or may not require referrals for specialty care
Total out-of-pocket costs are typically higher than an HMO but lower than a PPO
Watch this short video to help figure out which type of plan is right for you.
What type of Medicare plan is right for me?
Still Have Questions About HMO and PPO Plans?
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