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HMO vs. PPO Medicare Advantage Plans: What are the Differences?

October 26, 2023

 HMO vs. PPO Medicare Advantage Plans: What are the Differences?

As we get closer to reaching our 65th birthdays, we need to start thinking about Medicare! At 65, you will become eligible for coverage and you'll need to be prepared to select a Medicare Advantage plan. We all want to have adequate and comprehensive medical coverage in case of an unexpected medical emergency and to keep up with our preventive care responsibilities. Before you select your Medicare Advantage plan, you have to know how to compare Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) plans. In this blog, we'll go over the difference between HMO and PPO Medicare plans so you can make a decision about which plan is right for you.


What is the difference between HMO and PPO Medicare plans?


 When it's time to select a Medicare Advantage insurance plan, you'll have to decide whether you want to go with an HMO or a PPO plan. Both options come with a host of benefits and some drawbacks, so it's vital to understand the distinctions between them. That's why we put together this basic overview for you.


Health Maintenance Organization Plans

HMO plans tend to have lower out-of-pocket costs and a restricted network. One feature of an HMO plan is that you'll need to choose a primary care physician (PCP) who will be responsible for coordinating all of your medical care. If you require care from a specialist, you will generally need a referral from your PCP. HMO plans are often suited for you if you prefer having a lower deductible and copay, and who are comfortable with a restricted network of providers.


Preferred Provider Organization Plans

PPO plans have a broader network of providers and offer greater flexibility. This means you don’t need to choose a PCP, and you can visit any provider within your PPO network without a referral. PPOs can have higher premiums, deductibles, and copays, though this is often worth it for many people due to the plan's ease of use. PPOs are frequently recommended for people who need more flexibility in their health care and prefer not to be limited to a particular provider network. Always remember that there is no one "best" type of plan, you need to choose the plan that works best for your individual situation.


Choosing the Right Medicare Plan

As discussed, the primary difference between HMO and PPO Medicare plans is the network of healthcare providers. HMO plans have a smaller network of providers, and you're typically required to get all of your healthcare services from providers within the plan's network. PPO plans, on the other hand, give you additional flexibility, allowing you to see in-network providers or out-of-network providers for a higher cost share. So, if you have specific healthcare providers that you want to see regularly, a PPO plan may be more suitable unless they are already part of the HMO's network.


Cost is always a consideration when making healthcare decisions, and choosing between an HMO and PPO Medicare Advantage plan certainly isn't an exception. While your HMO plan may have lower premiums and deductibles, there is a trade-off you will have to manage in terms of your plan's flexibility. A PPO gives you optimal flexibility, but the premiums can be higher on a monthly basis. Balancing cost and flexibility is the key to finding the right plan for your lifestyle and your budget.


Remember that your needs are based on your medical history and your health situation. The balance of coverage and cost-efficiency that's best for you may not be what's best for someone else. That's why you take the time to review each plan's features, particularly with regard to prescription drug coverage. Talking to a licensed insurance agent, like ours here at, can be extremely useful.


When do you need to enroll in your Medicare Advantage plan?



If you don't sign up during the proper Medicare Advantage enrollment period, you could end up being penalized for it. In some cases, you may need to wait to enroll until the next open enrollment period. Certain life events, like a move or loss of employer-provided health insurance, may qualify you for a special enrollment period. Look up the appropriate dates so that when you're done researching the difference between HMO and PPO Medicare plans, you can select the Medicare coverage you need to stay healthy and financially secure. The Medicare Advantage enrollment dates to be aware of are as follows:

  1. Medicare Initial Enrollment Period (IEP): The IEP begins three months right before the month of your 65th birthday and lasts for seven months in total. During the IEP, you can sign up for the health care coverage you need, without facing any late enrollment penalties. If you don't enroll during your IEP, it can lead to gaps in coverage.
  2. Medicare Annual Enrollment Period (AEP): The Medicare AEP, on the other hand, is the time of year when you can make changes to your coverage if you're already enrolled in Medicare. This period occurs every year from October 15 to December 7. Unlike the IEP, which only lasts for up to seven months, the AEP is strictly limited to a two-month window.
  3. Medicare Advantage Open Enrollment Period (MA-OEP): The MA-OEP is a unique time frame that allows Medicare beneficiaries enrolled in a Medicare Advantage plan to make changes to their coverage. The MA-OEP only takes place from January 1 to March 31, and it gives you the flexibility to switch to another Medicare Advantage plan, switch back to Original Medicare, enroll in a Part D prescription drug plan, or change to a different Medicare Advantage plan that includes prescription drug coverage.
  4. Medicare Special Enrollment Period (SEP). During the Medicare SEP, you can make changes or enroll in Medicare outside of the typical enrollment periods in certain circumstances. This program was created to ensure you can access the health care coverage you need, even when you experience life-changing events that may occur outside of the normal enrollment periods.


Enrolling in a Medicare Advantage Plan Online



Good news: enrolling in Medicare Advantage just got a whole lot easier thanks to the power of the internet! By taking advantage of the many online resources available, you can now research, compare, and understand the difference between HMO and PPO Medicare plans. Then, you can sign up for a Medicare Advantage plan from the comfort of your own home. Our resources allow you to research and compare different plans based on your unique needs and preferences, such as cost, coverage, and network of providers. Once you’ve found a plan that you would like to enroll in, you can complete the application process entirely online.

Signing up for a Medicare Advantage plan is a critical decision for many people, and now the process is more accessible than ever. The internet has given everyone the ability to be more involved in their care, so you can feel confident that you’re making an informed decision to get the coverage that you need. So why wait? Start exploring your Medicare Advantage options today and enjoy the benefits of a simplified enrollment process. Call us on weekdays from 8 a.m. to 8 p.m. at 1-800-620-4519 (TTY 711) to speak to a licensed insurance agent and start your journey with Medicare.


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