Medicare HMO and PPO plans are two types of Medicare Advantage plans.
HMO stands for health maintenance organization. PPO stands for preferred provider organization.
Both plans help you get care, but they work in different ways. The main differences are:
- The doctors you can see
- Whether you need a referral to see a specialist
- How much you may pay for your care
What’s a Medicare HMO plan?
An HMO plan uses a set of doctors and hospitals, called a network. You choose a main doctor, called a primary care provider (PCP). Your PCP helps guide your care and may refer you to a specialist.
This plan may cost less, but you may have fewer doctors and hospitals to choose from.
With an HMO plan, you usually need to:
- Choose a PCP
- Get a referral from your PCP before you see a specialist
- Use doctors and hospitals in the plan’s network for covered care, except in an emergency
What’s a Medicare PPO plan?
A PPO plan gives you more choices in where you get care. You can see doctors and hospitals in or out of the plan’s network. You’ll usually pay less when you stay in network.
This plan may cost more, but you may have more doctors and hospitals to choose from.
With a PPO plan, you can:
- See any doctor or specialist without a referral
- Use providers outside the plan’s network, but it may cost more
- Choose where you receive care
How are HMO and PPO provider networks different?
HMO and PPO plans have different rules for seeing doctors. Use this chart to compare them.
| What to compare | HMO plans | PPO plans |
|---|---|---|
| Doctors you can see | You need to use doctors in the plan’s network. | You can use in-network and out-of-network providers. |
| Getting care outside the plan’s network | Care is usually not covered, except in emergencies. | Care is covered, but you may pay more. |
| Specialists | You usually need a referral to see specialists. | You usually don't need a referral to see specialists. |
| Costs | You pay less when you stay in network. | You pay more when you go out of network. |
What are the cost differences between HMO and PPO plans?
Costs depend on the plan and where you get care. HMO plans often cost less when you use doctors in the plan’s network. PPO plans may cost more, but they give you more choice in where you get care.
HMO plans may have:
Lower monthly premiums (what you pay each month for your plan)
Lower costs when you stay in network
PPO plans may have:
Higher monthly payments
Higher costs when you go out of network
Drug costs can also be different by plan. They depend on your plan’s drug list, the drug tier and the pharmacy you use.
How do I choose between an HMO and a PPO plan?
Choosing the right plan depends on your health needs, how much you can spend and how much choice you want.
When you compare plans, think about:
Are your doctors in the plan’s network?
How often do you see specialists?
Do you want to see doctors outside the network?
How much do you want to pay for your plan and for your care?
If you want lower costs and don’t mind staying in network, an HMO plan is a good fit.
If you want more doctor choices and don’t mind paying more for some of your care, a PPO plan may be a better option.
Common questions about Medicare HMO and PPO plans
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If you travel often or live in more than one place, a PPO plan may be better for you. It gives you more choices for where to get care, but you may pay more. Check the plan costs before you enroll.
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You may be able to change your Aetna® Medicare Advantage plan during certain enrollment periods:
- The Annual Enrollment Period (AEP) which runs from October 15 through December 7 each year.
- A Special Enrollment Period (SEP) if you have a certain life event.
Check your options to see when you can change your plan, and what it may cover.
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Maybe. It depends on the plan you choose:
With an HMO plan, your PCP usually needs to be in the plan’s network.
With a PPO plan, you may be able to keep your PCP even if they are out of network. But you may pay more.
Before you choose a plan, make sure these are covered where you live:
Your PCP
Your doctors and hospitals
Your prescriptions
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It depends on the plan. Dental coverage and costs can be different. With an HMO plan, you usually need to use dentists in the plan’s network. A PPO plan may give you more choices, including some dentists outside the network.
Check each plan’s dental benefits, network and costs to find one that works for you.
Explore Aetna Medicare plan options
We offer Medicare Advantage plan types in many areas, including HMO, HMO-POS and PPO plans. Learn more about each plan.
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Enter your ZIP code to find Aetna Medicare plans in your area. Compare benefits, costs and drug coverage and see if your providers are in our network.
