What is the difference between a Medicare Advantage HMO and a PPO?

How do HMO and PPO networks differ?

HMO and PPO networks differ in whether out-of-network care is covered. In a Medicare Advantage Health Maintenance Organization (HMO), you generally must get care and services from doctors, other health care providers and hospitals in the plan's network, except for emergency care, out-of-area urgent care and temporary out-of-area dialysis. If you get non-emergency care outside an HMO's network without authorization, you may have to pay the full cost.

A Medicare Advantage Preferred Provider Organization (PPO) has a network too, and you pay less when you use it. You can also use out-of-network providers for covered services, usually for a higher cost, if the provider participates in Medicare or accepts assignment, agrees to treat you and hasn't opted out of Medicare. Medicare.gov suggests contacting the PPO before an out-of-network service to make sure it's medically necessary and covered. You're always covered for emergency and urgent care.

Do I need a primary care doctor or referrals?

In most Medicare Advantage HMOs, yes to both: you choose a primary care doctor, and in most cases you need a referral to see a specialist. Certain services, like yearly screening mammograms, don't require a referral.

In a Medicare Advantage PPO, you don't have to choose a primary care doctor and in most cases you don't need a referral. Your costs for covered services are usually lower when you use the plan's in-network specialists than when you use specialists outside the network.

What is an HMO Point-of-Service (HMO-POS) plan?

An HMO-POS plan is an HMO that may let you get some services out of network for a higher copayment or coinsurance. Medicare.gov notes that it's important to follow the plan's rules, like getting prior approval for a certain service when the plan requires it. Which services an HMO-POS covers out of network, and what you pay, vary by plan.

What do Medicare Advantage HMOs and PPOs cost?

Costs vary by plan. Medicare.gov says many HMOs and PPOs charge a monthly premium in addition to the Part B premium, and some Medicare Advantage plans have a $0 premium, though you may still pay the Part B premium. What you pay also depends on the plan's deductibles, copayments and coinsurance, how often you need care, and whether you use network providers.

Every Medicare Advantage plan has a yearly limit on what you pay out of pocket for covered Part A and Part B services, which may include different limits for in-network and out-of-network services. Once you reach the limit, you pay nothing for covered services for the rest of the year. CMS caps these limits: for 2026, a plan's limit can be no higher than $9,250 for in-network services and $13,900 for in-network and out-of-network services combined. Plans can't charge more than Original Medicare for certain services, like chemotherapy, dialysis and days 21 to 100 of skilled nursing facility care.

What rules apply to both HMOs and PPOs?

Medicare Advantage HMOs and PPOs must cover all medically necessary services that Original Medicare covers, and some offer extra benefits; rules and costs vary by plan. Both may require prior approval (prior authorization) for certain services. If a plan approves a treatment, the approval must be valid for as long as the treatment is medically necessary, and if you switch plans during treatment, the new plan must give you at least 90 days before it can ask for a new approval. See how prior authorization works in Medicare Advantage.

Most HMOs and PPOs include Medicare drug coverage (Part D). If you join an HMO or PPO without drug coverage, you can't join a separate Medicare drug plan. If your doctor leaves the plan's network, the plan will notify you if it's a primary care or behavioral health provider you've seen in the past three years (and in certain situations for other providers), and you can choose a new provider; you usually can't change plans because of this, though you may qualify for a Special Enrollment Period.

When can I join or switch between an HMO and a PPO?

You must have Part A and Part B and live in the plan's service area to join. You can join, switch or drop a Medicare Advantage plan during the Open Enrollment Period, October 15 to December 7, with coverage starting January 1. If you're already in a Medicare Advantage plan, you can make one change, such as switching from an HMO to a PPO, during the Medicare Advantage Open Enrollment Period, January 1 to March 31. Certain life events, like moving, can give you a Special Enrollment Period. See Can I change my Medicare plan, and when?.