Difference between hmo and ppo medicare advantage plans

First, let’s start with Original Medicare

Medicare is basic health insurance provided by the Federal government for people 65 and older, and people under 65 who meet certain criteria. When you sign up for Medicare, you are signing up for Part A and Part B. This is the first step to completing your Medicare coverage.

Medicare consists of 4 separate parts:

• Part A (Part of Original Medicare offered by the Federal government)
• Part B (Part of Original Medicare offered by the Federal government)
• Part C (Medicare Advantage plans offered by private insurance companies)
• Part D (Drug coverage offered by private insurance companies)

Why do you need additional coverage?

Many people discover that relying on Original Medicare (Part A and Part B) doesn’t provide enough coverage. With Original Medicare, there are gaps in your coverage. For example, Original Medicare only covers 80% of Part B expenses after the annual Part B deductible is met. The remaining 20% is your responsibility and could add up to thousands of dollars each year. Plus, Original Medicare doesn’t include Part D prescription drug coverage, routine vision and hearing exams, and certain other services.

In order to have enough coverage, many people choose to enroll in a Medicare Advantage plan.

How does an HMO plan work?

An HMO plan is a Medicare Advantage plan (Part C) that offers everything Medicare covers plus additional benefits such as prescription drug coverage (Part D), vision and hearing exams, preventive dental coverage, and discounts on fitness programs. In addition, Medicare Advantage HMO plans can help save you money with monthly premiums as low as $0 and an out-of-pocket maximum that limits what you pay for medical services in a year.

With a Medicare Advantage HMO plan, you choose a primary care physician or PCP to be your main doctor. Your PCP keeps track of all the care you receive and refers you to specialists if needed. Your PCP makes sure you get the care that is right for you. Your PCP can also help you avoid unnecessary expenses such as duplicate tests. This is one of the advantages of an HMO plan—having a team behind you to make sure you are getting the right care.

How does a PPO plan work?

A PPO plan is also a Medicare Advantage Plan (Part C), but it works differently than an HMO plan. With a PPO plan, you don’t have a PCP. Instead, you can access any doctor or hospital, but you would be responsible for coordinating your care. Seeing doctors inside the network will generally have lower costs for services than seeing a doctor outside of the network. A PPO plan provides everything Medicare covers plus additional benefits such as prescription drug coverage (Part D), vision and hearing exams, preventive dental coverage, and more. A PPO plan can have a monthly premium as low as $0 and an out-of-pocket maximum that limits what you pay for medical services in a year.

Which is right for you?

Choosing between an HMO and a PPO plan comes down to how you see your doctor. An HMO plan will provide more of a partnership with your doctor, and a PPO plan will allow you to access any doctor or hospital. At CarePartners of Connecticut, we have a team of Medicare Agents available to answer all your Medicare questions and help you find the plan that’s right for you. CarePartners of Connecticut offers several HMO plans and a CarePartners Access PPO plan. Just call 1-888-341-1507 (TTY: 711).

You can also compare plans on our website.

You might have faced the HMO vs. PPO* (Health Maintenance Organization vs. Preferred Provider Organization) decision if your employer offered a choice of these types of group health insurance plans. Now that you’re planning for Medicare, you might have a similar choice if you decide to get coverage through Medicare Advantage.

Let’s take a closer look at HMO vs. PPO Medicare Advantage plans to fully understand the differences.

Medicare Advantage HMO vs. PPO plans: how they’re alike

Both Medicare Advantage HMO plans and Medicare Advantage PPO plans are offered through the Medicare Advantage program (Medicare Part C). Here are some other “HMO vs. PPO” similarities:

• They’re available through private insurance companies that contract with Medicare.
• Both deliver your Medicare Part A (hospital insurance) and Part B (medical insurance) benefits. Hospice benefits are the one exception – those come directly through Medicare Part A instead of through the plan
• Both typically use provider networks
• They usually include prescription drug coverage and may have preferred pharmacy networks.
• Like any Medicare Advantage plan, both require you to have Medicare Part A and Part B, and to live within the plan’s service area.

Medicare Advantage HMO vs. PPO plans: how they’re different

Medicare Advantage HMO plans and PPO plans are probably more alike than different. But there are a few “HMO vs. PPO” contrasts:

• Although they generally have provider networks, Medicare Advantage PPOs let you see doctors outside the plan network. You might have to pay higher coinsurance or copayments for seeing out-of-network providers.
• You don’t have to choose a primary care provider with a Medicare PPO, but you do with an HMO.
• If you want to see a specialist, an HMO generally requires you to get a referral. A PPO typically lets you see a specialist without a referral.

Although Medicare Advantage PPO plans may offer more flexibility, your costs (such as the monthly premium) are generally higher under a PPO.

You might need to take a more active role in care coordination in a PPO plan.  For example, if you see providers outside the Medicare Advantage PPO plan’s network, you may have to give information about the medical care you have received and your prescription drugs to doctors who treat you.

With any type of Medicare Advantage plan, you’ll need to keep paying your Medicare Part B monthly premium, as well as any premium the plan might charge.

The pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year.

*Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. For a decision about whether the plan will cover an out-of-network service, you or your provider are encouraged to ask for a pre-service organization determination before you receive the service. Please call the plan’s customer service number or see your Evidence of Coverage for more information, including the cost sharing that applies to out-of-network services.

Ready to start exploring Medicare Advantage plans? Start here.