When you compare Medicare Advantage plans, you’ll see letters like HMO and PPO. They describe how a plan’s network works, which affects which doctors you can see, whether you need referrals, and what you pay.
HMO (Health Maintenance Organization)
- Network: You generally must use doctors, hospitals, and providers in the plan’s network, except in emergencies or for urgently needed care.
- Primary care doctor: You usually choose a primary care physician (PCP) who coordinates your care.
- Referrals: Many HMOs require a referral from your PCP to see a specialist.
- Costs: HMOs often have lower premiums and copays in exchange for less flexibility.
Some plans are HMO-POS (Point of Service), which allow certain services outside the network, usually at a higher cost.
PPO (Preferred Provider Organization)
- Network: PPOs have a network, but you can also see out-of-network providers, usually for a higher cost.
- Referrals: Usually not required to see a specialist.
- Costs: More flexibility often means higher premiums or copays than an HMO.
Keep in mind that out-of-network providers aren’t required to accept you, except in emergencies, so it’s best to confirm before you go.
Questions to ask yourself
- Are my current doctors in the network? This is often the deciding factor.
- Do I see specialists often? If so, consider whether referrals would be a hassle.
- Do I travel or split time between places? A PPO’s out-of-network coverage may matter more.
- What’s my budget? Compare premiums, copays, and the plan’s out-of-pocket maximum, not just one number.
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This article is for general educational purposes and is not a recommendation of any specific plan. Plan availability, benefits, and costs vary by plan and county and may change each year. For complete information, contact Medicare.gov or 1-800-MEDICARE.