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
What to Do When Your Doctor Leaves Your Network
Jul 15, 2025
Can I Change Medicare Advantage Plans Any Time? | Medicare Plans
Sep 19, 2022
Does Medicare Cover Inqovi?
Jan 11, 2023
Does Medicare Cover Lipoma Removal?
Dec 8, 2022
Is Emsella Covered by Medicare?
Nov 21, 2022
Does Medicare Pay for Bunion Surgery?
Nov 29, 2022
How Can I Get a Replacement Medicare Card?
Aug 14, 2023
How Are Medicare Star Ratings Determined?
Sep 6, 2023
Does Medicare Cover Tymlos?
Dec 5, 2022
Does Medicare Cover Hearing Aids?
Nov 9, 2022
Does Medicare Cover Cosmetic Surgery?
Nov 28, 2022
Does Medicare Cover Inspire for Sleep Apnea?
Dec 27, 2022
Are Medicare Advantage Plans Bad?
May 5, 2022
Can Medicare Advantage Plans Deny Coverage for Pre-Existing Conditions?
Mar 28, 2023
Does Medicare Cover Penile Implant Surgery?
Dec 9, 2022
How Much Does a Medicare Coach Cost?
Mar 20, 2023
Medicare & Ozempic
Jul 20, 2023
15 Best Ways for Seniors to Stay Active in Denver
Mar 9, 2023
10 Top Medicare Supplement (Medigap) Companies for 2025
13 Best Ways for Seniors to Stay Active in Columbus
13 Best Ways for Seniors to Stay Active in Jacksonville
13 Best Ways for Seniors to Stay Active in Phoenix
20 Questions to Ask Your Medicare Agent
2025 Medicare Price Changes
Can I Change My Primary Care Provider with an Advantage Plan?
Can I Choose Marketplace Coverage Instead of Medicare?
Can I Laminate My Medicare Card?
Can Medicare Help with the Cost of Tyrvaya?
Comparing All Medigap Plans | Chart Updated for 2025
Do I Need Medicare If My Spouse Has Insurance?
Do Medicare Supplement Plans Cover Dental and Vision?
Does Medicare Cover a Spinal Cord Stimulator?
Does Medicare Cover Bariatric Surgery?
Does Medicare Cover Bladder Sling Surgery?
Does Medicare Cover Cala Trio?
Does Medicare Cover Cardiac Ablation?
Does Medicare Cover Cervical Disc Replacement?
Does Medicare cover Deviated Septum Surgery?
Does Medicare Cover Driving Evaluations?
Does Medicare Cover ESRD Treatments?
Does Medicare Cover Incontinence Supplies?
Does Medicare Cover Medical Marijuana?
Does Medicare Cover Mouth Guards for Sleep Apnea?
Does Medicare Cover Nuedexta?
Does Medicare Cover Ofev?
Does Medicare Cover Orthodontic Care?
Does Medicare Cover Oxybutynin?
Does Medicare Cover Ozempic?
Does Medicare Cover RSV Vaccines?
Does Medicare Cover Scleral Lenses?
Does Medicare Cover SIBO Testing?
Does Medicare Cover Urodynamic Testing?
Does Medicare Pay for Antivenom?
Does Medicare Pay for Funeral Expenses?
Does Medicare pay for Opdivo?
Does Medicare Pay for Varicose Vein Treatment?
Does Retiring at Age 62 Make Me Eligible for Medicare?
Does Your Medicare Plan Cover B12 Shots?
Estimating Prescription Drug Costs
Explaining IRMAA on Medicare
How Do I Sign up for Medicare? A Simple How-To Guide For You
How Much Does a Pacemaker Cost with Medicare?
How to Apply for Medicare?
How to Become a Medicare Agent
How to Deduct Medicare Expenses from Your Taxes
Is Balloon Sinuplasty Covered by Medicare?
Is Displacement Affecting Your Medicare Coverage?
Is Fair Square Medicare Legitimate?
Is PAE Covered by Medicare?
Last Day to Change Your Medicare Part D Plan
Medicare 101
Medigap vs. Medicare Advantage
Plan G vs. Plan N
Should You Work With A Remote Medicare Agent?
The Fair Square Bulletin: October 2023
Top 10 Physical Therapy Clinics in San Diego
Turning 65 and Thinking of Keeping COBRA? Here’s Why It Usually Backfires
What Are Medicare Part B Excess Charges?
What Happens to Unused Medicare Set-Aside Funds?
What If I Don't Like My Plan?
What Is a Medicare Supplement SELECT Plan?
What Is Medical Underwriting for Medigap?
What Is the Medicare Birthday Rule in Nevada?
What is the Medicare ICEP?
What People Don't Realize About Medicare
What to Do When Your Doctor Doesn't Take Medicare
When to Choose Medicare Advantage over Medicare Supplement
Which Medigap Policies Provide Coverage for Long-Term Care?
Why You Should Keep Your Medigap Plan
Will Medicare Cover Dental Implants?
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
Fair Square Medicare