When you enroll in a Medicare Advantage Plan
While there are several good health plans to choose from, the two most popular options include HMO (Health Maintenance Organization) and PPO (Preferred Provider Organization) plans.
What exactly do these plans have to offer? How do they differ in terms of coverage?
Keep reading to find out. We'll answer all your questions about HMOs and PPOs so you can decide which health plan is best for you.
An HMO (Health Maintenance Organization) plan is one type of Medicare Advantage health plan. HMOs have a specific network of doctors and hospitals. To get coverage, you must receive medical care within this network.
Here's what to expect if you enroll in an HMO plan:
No coverage outside your network (except for emergency care)
Low monthly premiums and deductibles
You have to select a primary care physician (PCP) to manage your healthcare needs
Your PCP must write a referral for you to visit a specialist
Prescription drugs are only covered if you're enrolled in an HMO plan with prescription drug coverage (and you must order these drugs from pharmacies within your network)
Your network covers only one laboratory provider for lab work (e.g., blood draws and urine tests)
A PPO (Preferred Provider Organization) plan is another type of Medicare Advantage plan. PPOs also have a network of doctors and hospitals, but they don't require you to stay within the network. However, you will likely have to pay more to go outside the network.
Here's what to expect if you enroll in a PPO plan:
Coverage both inside and outside your network (Note: Copays and out-of-pocket costs might be higher for out-of-network providers)
Higher monthly premiums
You don't need to select a PCP
You don't need PCP referrals to see a specialist
Prescription drugs are only covered if you're enrolled in a PPO plan with prescription drug coverage. (You can order prescription drugs from any pharmacy, but choosing pharmacies within your network might be cheaper)
You have more coverage options for your lab work
HMO and PPO plans differ when it comes to:
Provider networks (in-network limitations and out-of-network coverage)
Costs (premiums)
PCP requirements
Expectations for filing reimbursement claims
Let's look at these differences in more detail.
Both HMO and PPO plans have specific networks of hospitals and doctors. But they differ in terms of network coverage.
HMO plans:
Provide coverage only when you visit an in-network doctor (i.e., they don't cover visits to out-of-network providers)
Have in-network limitations for lab work and prescription drugs. You'll need to stick to labs and pharmacies within the network to get coverage for your blood tests, urine tests or prescription drugs
PPO plans:
Provide coverage even when you see a doctor outside the network (Note: You might have a higher copay for out-of-network visits)
Don't have in-network limitations for lab work and prescription drugs
The costs will vary depending on which plan you sign up for. But the following points might indicate patterns of what you could expect to pay.
HMO plans:
Low premiums
Low (or no) deductibles
Only require a copay when you receive healthcare services
PPO plans:
High monthly premiums
Include deductibles, copays, and coinsurance when you receive healthcare services
HMO plans:
Require you to select a primary care physician (PCP) from within the network
Require a referral from your PCP to consult a specialist
Cover specialist consultations only when you have a referral
PPO plans:
Don't require you to have a PCP
Let you visit any doctor (or specialist) without a referral
HMO plans:
Don't require you to file a claim (since your healthcare services only come from in-network providers)
PPO plans:
Ask that you pay out-of-network providers directly and then file a claim for reimbursement
The right health plan for you totally depends on your needs. Let's run through a few scenarios:
You're in good health — HMO
If you have no major health issues and your favorite doctor is within the network, choose an HMO.
You're looking for an affordable plan — HMO
HMO plans might have lower monthly premiums and sometimes have zero deductibles.
You travel a lot — PPO
A PPO plan is best for frequent travelers since it doesn't limit you to only in-network providers. You can visit any doctor outside the network, even when you're away from home.
You live in a rural area — PPO
A PPO plan is a good option if you live in a rural area with very few doctors within your network.
If you're trying to decide between an HMO and a PPO plan, start by comparing their out-of-network coverage, costs, PCP requirements, and expectations for filing reimbursement claims. You should also consider factors like location, personal health, traveling frequency, and budget.
If you feel stuck, our team at Fair Square Medicare Medicare
Does Medicare Cover a Spinal Cord Stimulator?
Nov 19, 2022
Does Medicare Cover Vitamins?
Dec 5, 2022
Does Medicare Cover Nuedexta?
Nov 30, 2022
Can I Change My Primary Care Provider with an Advantage Plan?
Aug 25, 2023
Does Medicare Cover Linx Surgery?
Dec 6, 2022
When to Choose Medicare Advantage over Medicare Supplement
Jun 7, 2023
Medicare Supplement Plans for Low-Income Seniors
Mar 23, 2023
Does Medicare Require a Referral for Audiology Exams?
Nov 22, 2022
Fair Square Bulletin: We're Revolutionizing Medicare
Apr 27, 2023
Does Retiring at Age 62 Make Me Eligible for Medicare?
Jun 16, 2022
Does Medicare Cover Scleral Lenses?
Dec 5, 2022
How Does the End of the COVID-19 Public Health Emergency Affect Your Medicare?
Mar 3, 2023
Will Medicare Cover Dental Implants?
Jun 2, 2022
Medicare Savings Programs in Kansas
Mar 22, 2023
13 Best Ways for Seniors to Stay Active in Indianapolis
Mar 9, 2023
What People Don't Realize About Medicare
Mar 27, 2023
How Much Does Trelegy Cost with Medicare?
Jan 24, 2023
Is Vitrectomy Surgery Covered by Medicare?
Dec 2, 2022
13 Best Ways for Seniors to Stay Active in Columbus
13 Best Ways for Seniors to Stay Active in Jacksonville
14 Best Ways for Seniors to Stay Active in Seattle
20 Questions to Ask Your Medicare Agent
2024 Cost of Living Adjustment
Are Medicare Advantage Plans Bad?
Can I Change Medicare Advantage Plans Any Time? | Medicare Plans
Can I switch From Medicare Advantage to Medigap?
Can Medicare Advantage Plans Deny Coverage for Pre-Existing Conditions?
Can Medicare Help with the Cost of Tyrvaya?
Comparing All Medigap Plans | Chart Updated for 2025
Denied Coverage? What to Do When Your Carrier Says No
Do You Need Medigap if You're Eligible for Both Medicare and Medicaid?
Does Medicare Cover Abortion Services?
Does Medicare Cover an FMT?
Does Medicare Cover Bladder Sling Surgery?
Does Medicare Cover Boniva?
Does Medicare Cover Cala Trio?
Does Medicare Cover Cartiva Implants?
Does Medicare Cover Cataract Surgery?
Does Medicare Cover Chiropractic Visits?
Does Medicare Cover Cold Laser Therapy (CLT)?
Does Medicare Cover Cosmetic Surgery?
Does Medicare Cover Diabetic Eye Exams?
Does Medicare Cover Exercise Physiology?
Does Medicare Cover Geri Chairs?
Does Medicare Cover Hoarding Cleanup?
Does Medicare Cover Hypnotherapy?
Does Medicare Cover Ilumya?
Does Medicare Cover Inspire for Sleep Apnea?
Does Medicare Cover Ketamine Infusion for Depression?
Does Medicare Cover Kyphoplasty?
Does Medicare Cover Light Therapy for Psoriasis?
Does Medicare Cover Mental Health?
Does Medicare Cover Penile Implant Surgery?
Does Medicare Cover Shock Wave Therapy for Plantar Fasciitis?
Does Medicare Cover the WATCHMAN Procedure?
Does Medicare Cover Urodynamic Testing?
Does Medicare Cover Zilretta?
Does Medicare Pay for Bunion Surgery?
How Are Medicare Star Ratings Determined?
How Do Medigap Premiums Vary?
How Does Medicare Cover Colonoscopies?
How Medicare Costs Can Pile Up
How Much Does a Pacemaker Cost with Medicare?
How Much Does Medicare Cost?
How Much Does Open Heart Surgery Cost with Medicare?
Is Botox Covered by Medicare?
Is Fair Square Medicare Legitimate?
Is PAE Covered by Medicare?
Medicare Consulting Services
Medicare Deductibles Resetting in 2025
Medigap Plan N vs. Plan G — Which One Fits You in 2025?
Medigap vs. Medicare Advantage
Moving? Here’s What Happens to Your Medicare Coverage
Saving Money with Alternative Pharmacies & Discount Programs
Should You Work With A Remote Medicare Agent?
Welcome to Fair Square's First Newsletter
What Happens to Unused Medicare Set-Aside Funds?
What If I Don't Like My Plan?
What Is a Medicare Advantage POS Plan?
What Is a Medicare Supplement SELECT Plan?
What Is Medical Underwriting for Medigap?
What is Plan J?
What is the 8-Minute Rule on Medicare?
What Is the Medicare Birthday Rule in Nevada?
What To Do If Your Medicare Advantage Plan Is Discontinued
What's the Difference Between HMO and PPO Plans?
Which Medigap Policies Provide Coverage for Long-Term Care?
Why Is Medicare So Confusing?
Why You Should Keep Your Medigap Plan
Will Medicare Cover it?
Get the Fair Square Bulletin
Medicare savings tips, helpful guides, and more.
Virgil Insurance Agency, LLC (DBA Fair Square Medicare) and www.fairsquaremedicare.com are privately owned and operated by Help Button Inc. Medicare supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program. This is a solicitation of insurance. A licensed agent/producer may contact you. Medicare Supplement insurance is available to those age 65 and older enrolled in Medicare Parts A and B and, in some states, to those under age 65 eligible for Medicare due to disability or End-Stage Renal disease. Virgil Insurance Agency is a licensed and certified representative of Medicare Advantage HMO, HMO SNP, PPO, PPO SNP and PFFS organizations and stand-alone PDP prescription drug plans. Each of the organizations we represent has a Medicare contract. Enrollment in any plan depends on contract renewal. The plans we represent do not discriminate on the basis of race, color, national origin, age, disability, or sex. Plan availability varies by region and state. For a complete list of available plans please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov. © 2025 Help Button Inc
We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.
MULTIPLAN_FairSquareMedicare_01062022_M