Frequently Asked Questions
What is the main difference between a Medicare Advantage HMO and PPO?
An HMO generally requires you to use doctors and hospitals in its network (except in emergencies) and often requires a referral from your primary care doctor to see a specialist. A PPO also has a network, but lets you see out-of-network providers for a higher cost, and usually does not require referrals. HMOs tend to have lower premiums; PPOs offer more flexibility.
Which is better for someone who travels?
A PPO is usually more flexible because out-of-network care is covered at a higher cost-share. An HMO may cover only emergency and urgent care outside its service area. If you spend months away from home, check how each plan handles care in another state before you enroll.
What is an HMO-POS plan?
A Point-of-Service (POS) HMO works like an HMO but lets you get some services out of network, usually at a higher cost. The exact services and costs vary by plan, so read the plan's Evidence of Coverage.
What are Special Needs Plans (SNPs)?
SNPs are Medicare Advantage plans designed for people with specific situations: those who have both Medicare and Medicaid (D-SNP), certain chronic conditions (C-SNP), or who live in an institution such as a nursing home (I-SNP). They coordinate care and may offer extra benefits tailored to the group.
Can I buy a Medigap policy if I have a Medicare Advantage plan?
No. Medigap works only with Original Medicare, and it is illegal for an insurer to knowingly sell you a Medigap policy while you are in a Medicare Advantage plan. If you return to Original Medicare, you may want a Medigap policy, but outside certain protected periods insurers in most states can use medical underwriting.
Choosing a Medicare Advantage plan involves two decisions: which insurer and plan, and which plan type. The type determines how much freedom you have to choose doctors and how much you pay when you go outside the network. Here is how each type works.
HMO — Lower Cost, Narrower Network
HMO plans are the most common Medicare Advantage type. You pick a primary care doctor, use the plan's network of doctors and hospitals, and typically need a referral to see specialists. Outside the network, the plan generally pays only for emergency and urgently needed care. In exchange, premiums and cost-sharing tend to be lower.
Best for: people whose doctors are already in the network, who are comfortable coordinating care through a primary care doctor, and who want lower costs.
PPO — More Flexibility, Higher Cost
PPO plans also have a network but let you see out-of-network providers at a higher cost, usually without a referral. This flexibility is valuable if you see specialists regularly, travel, or live in two places. The trade-off is typically higher premiums and higher cost-sharing, and some out-of-network providers may decline to bill the plan.
Best for: people who want choice of specialists, who travel, or who have doctors that might not be in a given network.
Other Types
- HMO-POS: an HMO with limited out-of-network options
- PFFS (Private Fee-for-Service): the plan sets what it pays, and providers must agree to accept the plan's terms; availability is limited in many areas
- SNPs: built for people with Medicare and Medicaid, certain chronic conditions, or institutional needs
- MSA (Medical Savings Account): a high-deductible plan paired with a deposit account; uncommon
How to Choose
- List your doctors, specialists, hospital, and pharmacy — then check each against the plan's network by calling the offices
- Decide how much you value freedom to go out of network versus lower cost
- Compare the plan's in-network out-of-pocket maximum — it caps your yearly costs for covered in-network care
- Check prior authorization rules for services you are likely to need
- Look at the plan's star rating and complaint history on Medicare.gov
- Verify each doctor's network status by phone — directories can be out of date
- Choose a PPO if you travel a lot or want specialist freedom
- Choose an HMO if your doctors are in the network and you want lower costs
- Remember you cannot add Medigap to a Medicare Advantage plan
→ How to Choose a Medicare Advantage Plan
→ Medicare Advantage vs Medigap
→ Using Star Ratings