HMO vs. PPO

The main differences between Medicare Advantage health maintenance organizations (HMO) and preferred provider organization (PPO) plans are rules that can affect how much you pay and how much flexibility you have in choosing your doctor and other providers.

HMO and PPO plans both rely on a network of doctors, hospitals and other health care providers who have agreed to specific prices for health care services. Using these providers will cost you less than going to those who don’t belong to the network.

Most HMO and PPO plans provide prescription drug coverage, but you should ask about that before buying a plan.

HMO plans can cost you less, but PPO plans give you greater flexibility of your choice of health care providers.

HMO plans are the most popular type of Medicare Advantage plans, accounting for 59% of all Medicare Advantage enrollees in 2022, according to the Kaiser Family Foundation.

They are typically more affordable, but come at the cost of flexibility in your health care choices. You are usually limited to a smaller, more localized network of providers and have to seek referrals or prior authorizations for certain medical services.

But if cost is your main concern, HMO plans may be a better choice.

The Centers for Medicare & Medicaid Services limits the maximum out-of-pocket expenses you have to pay to $7,550 for in-network services and $11,300 for in-network and out-of-network combined in 2022. But maximum out-of-pocket costs are also considerably lower for HMO plans than for PPO plans.

According to the Kaiser Family Foundation, 38% of Medicare Advantage enrollees are in PPO plans. PPO plans are the second most popular type of Medicare Advantage plans, largely due to their flexibility in your choice of doctors and other providers.

HMO plans require you to name a primary care physician to coordinate all your health care. PPO plans don’t have this requirement and give you greater ability to choose the doctors, specialists and other providers you want, similar to other Medicare plans.

PPO plans also give you greater flexibility in choosing a doctor or other provider outside your PPO network. But you may have to pay more for each visit or service.

You generally will not need a referral if you have a PPO plan. But you will typically pay less if you use specialists in your plan’s network than an out-of-network specialist.

This differs from HMO plans which typically require a referral from your primary care physician to coordinate your medical care.

Most Medicare Advantage plans may require prior authorization for some expensive services. This is less likely with PPO plans, but you should check with your plan’s administrator to see if you will need prior authorization for certain services.

When comparing HMO vs. PPO plans, there are two major considerations to take into account to decide which one is best for you: Your current, individual needs and your future needs.

For your current needs, don’t focus on the cost of the monthly premium. You need to weigh your total health care costs. Consider your deductible, copayments and coinsurance costs you’ll have to pay out of your pocket over time. And be aware of the limit a plan puts on your annual out-of-pocket costs.

For your future needs, you need to consider whether saving money on monthly premiums now is the wisest choice. Or you may prefer the flexibility of more providers and lower deductibles later.

In addition to these considerations, there are other options and contingencies that you need to think about before deciding whether to go with an HMO plan or a PPO.