There are several different types of Medicare Advantage plans from which to choose, and two of the most popular kinds are Medicare HMO’s and Medicare PPO’s.
Let’s compare these two types of plans to better understand how they are different and help you determine which one might be best for you.
HMO stands for “Health Maintenance Organization.”
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This type of plan typically utilizes a primary care physician. A primary care physician is a general practice doctor whom you will almost always see first. This doctor can perform a wide range of treatments and may be able to treat the majority of your ailments.
An HMO plan is typically made up of an approved network of health care providers. In most cases, any medical care you receive will only be covered by your plan if you visit a provider from within the plan network.
If you seek medical care outside of your network, you may have to pay the full cost of the services you receive. One exception is in the event of an emergency.
If you need specialized treatment from a specialist, your primary care physician will refer you to the appropriate doctor within the HMO plan’s network and help you set up an appointment.
PPO stands for “Preferred Provider Organization.”
With a Medicare PPO, you are free to visit the health care provider of your choice. The PPO plan will have a network of providers (similar to as with an HMO plan), and you will typically have lower out-of-pocket costs if you stay within that network.
Unlike an HMO plan, a PPO plan my cover some of the costs for care you receive outside of the plan network. However, you will likely pay higher out-of-pocket costs for care you receive outside of the network.
You are typically not required to designate a primary care physician when you join a PPO plan. This can give you a little more freedom to choose your providers and to seek the care of a specialist without having to get a referral from a primary care doctor.
Some Medicare PPO plans are local PPO plans, and some are regional PPO plans. These designations have to do with the specific plan coverage area.
HMO plans are the most popular type of Medicare Advantage plan in the U.S. by a fairly large margin.
In 2021, 62 percent of all Medicare Advantage plans offered are Medicare HMO plans. 33 percent of all available Medicare Advantage plans are Medicare PPO plans in 2021.1
According to the Kaiser Family Foundation, members of Medicare Advantage HMO plans that included prescription drug coverage paid an average premium of $23 per month in 2019.2
Members of regional PPO plans with drug coverage paid an average premium of $44 per month in 2020, while members of local PPO plans with drug coverage paid an average premium of $39 per month.
Two things that are worth noting about these costs:
There are a few key differences between HMO and PPO plans.
Despite their differences, HMO and PPO Medicare Advantage plans have a lot in common.
Both types of Medicare Advantage plans provide the same basic coverage as Medicare Part A (hospital insurance) and Part B (medical insurance) into one single plan.
Many Medicare HMO and Medicare PPO plans may also include additional benefits not covered by Original Medicare.
Some of these additional benefits can include:
Some Medicare Advantage plans may offer even more additional benefits. These benefits can vary based on your location and the plan provider.
The benefits of an HMO plan may include:
The benefits of a PPO plan may include:
While some people enjoy having their care coordinated by a primary care physician, others prefer the freedom and flexibility of making their own health care decisions.
Each type of Medicare Advantage plan has its own benefits, and choosing between an HMO and a PPO is entirely up to your health care needs and budget.
Some people might enjoy having a primary care physician. This doctor will get to know you and your health, and you can establish a trusting and long-lasting relationship.
Some people also like the coordinated care they experience in an HMO plan, where the providers in the network take more of a team approach to your care.
Other people may enjoy the freedom and flexibility that comes along with a PPO plan.
To learn more about HMO and PPO Medicare Advantage plans, and to find out which options are available where you live, call to speak with a licensed insurance agent. You can also compare plans online for free, with no obligation to enroll.
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1 Fugelsten Biniek, J. et al. (Oct. 29, 2020). Medicare Advantage 2021 Spotlight: First Look. Retrieved from https://www.kff.org/issue-brief/medicare-advantage-2021-spotlight-first-look.
2 Kaiser Foundation. Medicare Advantage 2017 Spotlight: Enrollment Market Update. Retrieved from https://www.kff.org/medicare/issue-brief/medicare-advantage-2017-spotlight-enrollment-market-update.
Christian Worstell is a senior Medicare and health insurance writer with MedicareAdvantage.com. He is also a licensed health insurance agent. Christian is well-known in the insurance industry for the thousands of educational articles he’s written, helping Americans better understand their health insurance and Medicare coverage.
Christian’s work as a Medicare expert has appeared in several top-tier and trade news outlets including Forbes, MarketWatch, WebMD and Yahoo! Finance.
Christian has written hundreds of articles for MedicareAvantage.com that teach Medicare beneficiaries the best practices for navigating Medicare. His articles are read by thousands of older Americans each month. By better understanding their health care coverage, readers may hopefully learn how to limit their out-of-pocket Medicare spending and access quality medical care.
Christian’s passion for his role stems from his desire to make a difference in the senior community. He strongly believes that the more beneficiaries know about their Medicare coverage, the better their overall health and wellness is as a result.
A current resident of Raleigh, Christian is a graduate of Shippensburg University with a bachelor’s degree in journalism.
If you’re a member of the media looking to connect with Christian, please don’t hesitate to email our public relations team at Mike@tzhealthmedia.com.