Choosing your Medicare health coverage is an important decision. This healthcare decision will determine the price you pay for coverage and services, the types of health services available to you, and the doctors you can see. For these reasons, this decision should not be taken lightly.

There are two general Medicare options to choose from for those eligible for Medicare (typically people age 65 and older): Original Medicare and Medicare Advantage. Original Medicare is the traditional program offered directly through the federal government, while Medicare Advantage is a plan offered by a private company but contracted with the federal government. While Original Medicare is generally cheaper, a Medicare Advantage plan offers additional benefits not traditionally offered by Original Medicare. These additional benefits can include routine exams, vision, hearing, and dental services.

If you decide to go with a Medicare Advantage Plan and take advantage of these additional benefits not provided by Original Medicare, you should know the difference between HMOs and PPOs.

There are two different kinds of Medicare Advantage Plans: Health Maintenance Organization plans (known as HMOs) and Preferred Provider Organization plans (aka PPOs). Both of these plans provide different kinds of benefits and below, we will outline their differences to help you make the decision about which Medicare Advantage Plan is right for you.

The Main Difference: Using Your Plan’s Provider Network

The main difference between PPO and HMO Medicare plans is the rules regarding using the provider network that the plan offers. A provider network is a group of hospitals and health care professionals that have signed a contract with a certain plan. These providers have reviewed and agreed to provide the services in the plan for the payment terms specified within the plan. This helps the plan manage costs because they know beforehand what the payment amount that they will receive will be. As result, the plan is then able to pass along these savings to members of the plan.

A Medicare Advantage HMO plan requires you to seek care from doctors, hospitals, and other medical professionals in your plan’s network. Care sought outside of the HMO network may not be covered by your plan.

There are, however, a few exceptions to the in-network rules for an HMO plan. The plan may cover out-of-network care under the following conditions:

  • You need urgent care and are outside your plan’s coverage area
  • You need emergency care
  • Dialysis outside your plan’s coverage area
  • Your plan covers a particular treatment that is not offered by in-network doctors in your area

In contrast, a Medicare Advantage PPO Plan has a list of preferred doctors, hospitals, and other medical professionals, but those using a PPO Plan do not have to use the services listed on the preferred list. However, you will get a discount for using the clinicians on the preferred list, you’ll be paying a larger co-pay for out-of-network providers, and you may have a larger deductible or limited coverage until you hit your deductible regarding out-of-network care.

Primary Care and Specialist Care

There are two additional differences between the care coverage provided by the two types of Medicare Advantage plans. Most HMO plans require you to be registered with a primary care provider and then obtain a referral to see a specialist if you need it. Your primary care provider will take care of your general medical needs and provide you with a referral to see specialists such as a cardiologist, gastroenterologist, or dermatologist.

On the other hand, PPO plans do not require you to choose a primary care provider, and generally, you will not need a referral to receive care from a specialist.

HMO vs PPO Costs

Medicare Advantage HMO plans can sometimes charge deductibles and premiums, but these costs are generally relatively low. The cost may even be free of charge. Usually, you will pay a co-payment (i.e., a set price for a specific service determined by your plan) for services covered under your plan once you have met the plan’s deductible.

Medicare Advantage PPO plans generally charge monthly premiums and deductibles, which may be higher than an HMO plan. Similarly, members of a PPO plan will usually be asked to make a co-payment for services covered under the plan once the plan’s deductible has been met.

So, Which is Best for You? Medicare Advantage HMO or PPO?

There is no right or wrong decision when choosing between HMO and PPO Medicare plans. The best plan for you should take into not only your finances but also the kind of medical treatment you are likely to require in the foreseeable future. HMO plans will generally be more cost-effective, but you may not be able to continue seeing your current doctors. We recommend taking the time to look at specific plans, their costs, and whether or not your current doctors are a part of their network before making the decision that best fits your needs.

To find more information about Medicare Advantage HMO and PPO plans in your specific location, you can click here.

Find Doctors and Specialists from the TopLine MD Alliance

Once you have signed up for a Medicare Advantage HMO or PPO plan, you may require a new doctor, specialist, or medical professional for your ongoing care. If your current doctor is no longer a part of your plan’s provider network or if your HMO plan requires you to be registered with a primary care provider for the first time, you may be required to find a new doctor – a process that can be stressful and taxing. Choosing a doctor is not a decision that should be taken lightly because you are placing your personal health in their hands.

This is where the TopLine MD Alliance can help and take the pressure off your shoulders. With the TopLine MD Alliance, you can discover top-rated primary care providers and specialists that fit your individual needs. You can trust that doctors within the Alliance offer ongoing patient satisfaction and consistent exceptional standards of care.

Providers in the TopLine MD Alliance can also collaborate together, allowing seamless communication between medical specialists, insurers, labs, and more. This can help streamline and simplify your overall medical experience.

Explore our website and the multiplicity of providers who are a part of the Alliance. Find a primary care provider or specialist who fits your health needs and is covered by your Medicare Advantage plan. You can then visit their website, give them a call, and make an appointment today.


The TopLine MD Alliance is an association of independent physicians and medical practice groups who are committed to providing a higher standard of healthcare services. The members of the TopLine MD Alliance have no legal or financial relationship with one another. The TopLine MD Alliance brand has no formal corporate, financial or legal ties to any of the affiliated physicians or practice groups.