HMO and PPO describe how a Medicare Advantage plan organizes access to medical care. The label helps you ask the right questions, but it does not tell you every benefit, price or provider. Compare the actual plan offered in your county for the correct year.
The practical differences
| Feature | HMO | PPO |
|---|---|---|
| Routine medical care | Generally uses the plan's network, with specified exceptions | Generally allows covered care outside the network, usually at a higher cost |
| Primary care doctor | Usually required | Generally not required |
| Specialist referral | Usually required, with some exceptions | Generally not required |
Do not confuse a referral with authorization
A referral comes from a provider. Prior authorization is a plan's approval for a service. A PPO may not require a specialist referral but can still require authorization for certain care. Ask about both requirements before scheduling a non-emergency service.
Verify care outside the network
Emergency and urgently needed care have protections, but that does not make routine out-of-network care unrestricted. Out-of-network providers are not required to treat plan members except in emergencies. Before a routine visit, confirm that the provider will see you, the service is covered and what you will owe. Check the Evidence of Coverage for the plan's specific rules.
Use a three-call check
- Ask the plan whether your doctor's exact name and practice address are in network.
- Ask the office whether it accepts that exact plan and is taking new patients.
- If a hospital or procedure is involved, ask whether separate clinicians or facilities will bill you.
Record the date, representative and reference number for each answer. Then compare premiums, medical deductibles, specialist costs and the applicable out-of-pocket limits. Choose based on the care you need and the rules you can use comfortably, not a claim that one plan type is universally better.
Continue with a related question
- How to Find and Verify a Medicare Provider
- Does Medicare Require a Referral to See a Specialist?
- Original Medicare or Medicare Advantage: Medical Benefits