HMO and PPO Medicare Plans

What is the Difference Between HMO and PPO Medicare Plans?

Medicare Advantage (MA) is a common option for Medicare beneficiaries who want all their Medicare coverage options under one policy. There are several types of MA plan options, including the Preferred Provider Organization (PPO) plans and Health Maintenance Organization (HMO) plans. In this post, we’ll explore the differences between Medicare Advantage HMO vs. PPO plans.

Health Maintenance Organization (HMO) vs. Preferred Provider Organization (PPO) Plans

Both HMO and PPO plans develop networks of doctors, hospitals, and health service providers to help keep down the cost. The major difference between these two plans is the flexibility provided to see other care providers outside their MA plan. Some of the differences between them include:

Plan Networks

An important feature of both plans is that they have networks. With networks, the cost of your healthcare will be lowered. This saves both health insurers and plan members’ money. Savings for health insurers can result in lower deductibles, copays, and premiums. PPO networks tend to be more flexible and broader, including more hospitals and doctors than HMO plans offer. However, the network will depend on the insurer and plan, so ensure to research each plan’s network before making any decision.

Primary Care Physicians

With HMOs, you’ll be required to choose a primary care physician who will be your main point of contact for your health needs. Your primary care physician will be responsible for determining the medical treatments you need and will refer you to specialists if he/she decides you need specialized medical care. Without a primary care physician referral, the specialist cost will not be covered. PPOs, on the other hand, don’t require the selection of primary care physicians, and you don’t need a referral to see a specialist.

Out-of-Network Care Coverage

For both HMOs and PPOs, the cost of receiving healthcare services from in-network providers is usually the lowest. Now when it comes to out of network care coverage, these two MA plans differ considerably. Out of network coverage is generally not covered for HMOs, except in the case of emergency. PPO plans, on the other hand, usually offer out of network coverage.  


The flexibility and additional coverage offered by PPO plans make it usually more expensive than HMO plans. PPO premiums are generally higher than HMO premiums. 

Deductibles are also another cost that needs to be considered. Not all Health Maintenance Organization have deductibles, but those that do are usually lower than Preferred Provider Organization deductibles.

Choosing the Right Plan

Now that you understand the significant differences between HMO and PPO plans, you may have an idea of the MA plan best suited for your budget and healthcare needs. But if you are still undecided between these two plans and need more information to decide, please contact Temmen Insurance.

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