830-217-6711

Seniors discussing various Medicare Advantage plans

HMO Plans vs. PPO Plans

Unlike Original Medicare, Medicare Advantage (Medicare Part C) coverage is based on the insurer’s preferred specifications. Getting the best Medicare Advantage (MA) plans usually involve choosing between Medicare Advantage Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO).

To choose the best Medicare Advantage plan for you, consider your budget and flexibility you need in a healthcare plan.

HMO PLANS

High Maintenance Organization (HMO) plans are for individuals who seek for a health insurance offered coverage through network of physicians. HMO plans allows beneficiary to visit a select network of doctors and specialists who work with your insurance provider. Generally, there are no exceptions to this rule unless if it comes to a case of medical emergency. HMO plans typically offers lower out-of-pocket expenses. The beneficiary is required to choose a Primary Care Physician (PCP) from the network of local healthcare providers under an HMO plan. A PCP is typically beneficiaries first point of contact for all health-related issues. This means that an insured person cannot see a specialist without a referral from their PCP. The average HMO plan can have a premium from $18 per month (average annualy premium is somewhere around $216). You may be responsible for a copayment each time you receive care, which is usually $5, $10, or $20 per service.

PPO PLANS

If you receive care from a doctor in the Preffered Provider Organization (PPO) network, the insurance company provides the highest level of coverage, and you pay the lowest out-of-pocket cost. PPO plans allow you to get medical care from a provider outside the network, but the services are covered at a much smaller percentage. One huge benefit is that a these plans does not require you to get a referral from your primary care doctor to see a specialist, but on the other hand PPO plans often require preauthorization for certain procedures, medications or types of care. The average cost for a PPO plan on a monthly basis for a 30-year-old is $458. PPO plans can be a good choice for individuals who want the flexibility to visit any doctor and hospital and to see specialists without a referral.


Now let’s compare the Medicare Advantage HMO and PPO Plans side by side on each differ point to help you understand which one might be right for your needs.

Provider Networks

One of the most significant differences between HMO and PPO Plans is the level of freedom a plan member has to go outside the healthcare providers network to receive coverage and care. With HMO, you must stay in the plan’s network if you want the plan to help you cover healthcare costs. However, the plan will pay its part during an emergency, regardless if care was received from the network provider or not.

With the Medicare Advantage PPO plan, a member has the option to go outside the network of the plan’s provider – though you will pay more if you receive care outside the plan’s network. Moreover, with an HMO plan, you must choose a primary care physician to coordinate your healthcare and refer you to specialists. In contrast, you don’t need a referral to see specialists or need a primary care physician with PPO.

Cost

HMO plans are typically less expensive than PPO plans. Several HMOs offer $0 monthly premiums with no annual deductible. HMOs mostly depend on care coordination by the small network provider to control costs and promote quality.

PPOs, on the other hand, have a monthly premium and annual deductible. However, the deductible only applies to the member that seeks out-of-network care. Usually, you will have to pay more for any service received outside the network. Besides that, the PPO copayments, coinsurance, and deductibles may be similar to HMO plans if the services are delivered by the plan’s network.

Services Covered

The coverage offered under Medicare Advantage HMO and Medicare Advantage PPO plans depends on the type of plan taken and the plan provider, but the services covered are usually similar.

Prescriptions Drug

HMOs also require you to get your prescription drugs filled and covered within the network as well. In contrast, PPOs allow you to fill a prescription anywhere though it comes with extra charges to get your prescription outside the network.

Which Medicare Advantage Plan is Better for You?

Each plan has its benefits, and selecting between the plans is entirely up to your healthcare needs and budget. Some Medicare beneficiaries like the HMO plan’s coordinated care, while others enjoy the flexibility and freedom that PPO plans offer.


To learn more about these plans and the best one for your needs, contact Turning 65 Solutions to speak with a licensed insurance agent.

Talk To Our Advisors

Feel Free To Reach Out Now