HMO vs PPO Medicare Advantage plans

Medicare Advantage HMO and PPO plans are similar but do have some distinct differences.

Here is how HMO and PPO plans are similar:

  • They are both available through private insurance companies that contract with Medicare.
  • They both cover your Medicare Part A and Part B benefits. Hospice care is always covered by Medicare Part A.
  • They both use provider networks
  • They both usually include prescription drug coverage and may have preferred pharmacy networks.
  • They both require you be enrolled in Medicare Part A and Part B, and to live within the plan’s service area.
  • They both require you pay the Medicare Part B monthly premium (Exception, you may get help with your Part B premium if you receive state Medicaid assistance)

Here is typically how HMO and PPO plans are different:


Must see providers in-network only. (unless for emergency).


Allowed to see providers outside the plan network but generally have to pay higher copays and coinsurance.

Must select a Primary Care Provider (PCP) when you first enroll.

To see a specialist, you generally need a referral from your Primary Care Physician (PCP).

Usually don’t have to select a Primary Care Provider, although it is recommended.

PPO plans typically allow you see a specialist without a referral.

*NOTE: Out-of-network providers are under no obligation to treat PPO plan members (except in emergency situations). While the plan lets you go outside of network, you should always verify ahead of time if your plan will cover the treatment or service from a particular out-of-network provider.

For more information on Medicare Advantage plans, click HERE and HERE.