Medicare HMO vs PPO – What is the Difference?

When you sign up for a Medicare Advantage (Part C) plan, you can choose different plan types: Medicare HMO or Medicare PPO. Both types of plans offer network and cost options. Find out more about the difference so you can select the one that best fits your budget and healthcare needs.

What is Medicare PPO (preferred provider organization)?

When you choose a Medicare PPO plan, you may pay less if you use the doctors and hospitals in the plan’s network. PPOs have large networks, but you can also see doctors that aren’t in the network. Plus, you don’t need a referral to see a specialist. Anthem MediBlue PPO is a Part C plan that gives you the flexibility to work with any doctor or specialist, in or out of network, no referrals needed.

What is Medicare HMO (health maintenance organization)?

When you choose a Medicare HMO plan, you get most of your care from a network of doctors and hospitals unless it is an emergency. You may also need a referral from a primary doctor to see a specialist. Anthem MediBlue HMO has all the benefits of a Medicare Advantage plan with access to our leading network of quality doctors.

Are PPO and HMO offered under Original Medicare?

PPO and HMO plans are only available through private insurers like Anthem as Medicare Advantage plans. If you are enrolling in Medicare for the first time, you’ll have to sign up for Original Medicare first. You can then choose a Medicare Advantage HMO or PPO plan that works for you.

PPO Medicare costs

PPO plans tend to have higher costs than HMO plans, and it costs more to see a doctor outside the network. You can choose a PPO plan for the flexibility.

HMO Medicare costs

HMO plan costs tend to be lower than PPO plans as long as you receive care within the network. Choosing doctors outside of the network or seeing a medical specialist without a referral from your primary care doctor will also cost more.

Prescription drug coverage by plan type

Depending on the plan, both PPO and HMO plan types can offer medical and prescription drug coverage for an all-in-one plan. If you take medications regularly, make sure to find a plan that provides that coverage.

Is Medicare PPO or HMO better?

Both types of plans offer different types of coverage based on cost and networks, so the best plan for you depends on your budget and your doctor preferences.

Medicare PPO is a better choice if:

• You are looking for more flexibility in the doctors you see.
• You don’t mind paying a little bit more for a plan with a larger network.
• You’d rather see a specialist or receive medical tests without a referral.

Medicare HMO is a better choice if:

• You like lower costs and don’t mind receiving care from a limited network of doctors.
• Doctors you would like to see are participating in the network.
• You like having a primary care physician coordinate all of your care and provide referrals for other specialists and other tests.

Can I switch from Medicare HMO to Medicare PPO?

Yes, you can change your plan type during the Medicare Annual Enrollment Period, which is October 15 to December 7. You can also change your Medicare Advantage plan type during the Medicare Open Enrollment Period, which is January 1 to March 31. In addition, you may have a Special Enrollment Period based on certain life events that affect your coverage. This Special Enrollment Period lets you switch to a different Medicare Advantage plan if you qualify.