Medicare Advantage: HMO vs. PPO

Medicare Advantage plans are available as HMOs (Health Maintenance Organization) and PPOs (Preferred Provider Organization). There are differences between the two, so you’ll need to choose the one that works best for your needs.

HMO vs. PPO: What are the differences?

 

The main differences between a PPO and an HMO are your ability to see out-of-network providers, costs, and network sizes.

A PPO lets you:

 

See the providers you prefer – both in and out of network – without a referral. Keep in mind, you may end up paying more when you see a provider outside the network.

An HMO requires you to:

 

See providers within your plan’s network. You may also need a referral to see a specialist.

Which one is better for you?

 

It really depends on the type of coverage you want and the doctors you’d like to see.

You might like PPOs better if:

 

  • You want flexibility to see the doctors you prefer
  • You don't mind paying more for a larger network
  • You'd like to see specialists without a referral

You might like HMOs better if:

 

  • You don’t mind having a specific network of doctors
  • You want lower premiums
  • You’d like your primary care doctor to coordinate your care and issue referrals to see a specialist

What about costs?

 

PPO plans may cost more in some cases, since they give you the freedom to go to the provider you prefer. They also include a larger network. PPOs typically have higher monthly premiums, co-pays, coinsurance, and deductibles if you see out-of-network providers.

Do both plans offer drug coverage?

 

Yes. Both PPO and HMO plans offer prescription drug (Medicare Part D) coverage. If you take meds regularly, you should check to make sure the plan you select includes your prescriptions.

Can I switch from an HMO to a PPO?

 

Yes, you can switch during the Medicare Annual Enrollment Period (AEP). You can also switch plans once during Medicare Advantage Open Enrollment, January 1 to March 31, or during a Special Enrollment Period (if you qualify).

Need more help navigating Medicare?

What is Medicare? 

 

What is Medicare Part C? 

 

Compare Medicare Advantage Plans 

 

Medicare Eligibility and Qualifications 

Wellpoint and Carelon Health plans are Medicare Advantage plans with Medicare contracts. Wellpoint and Carelon Health plans are SNP plans with a Medicare contract and a contract with the state Medicaid program. Enrollment in Wellpoint or Carelon Health depends on contract renewal.

 

Out-of-network/non-contracted providers are under no obligation to treat Plan members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.