Medicare HMO Vs. PPO – What Is The Difference?

Comparing Medicare HMO Vs. PPO Plans


When you sign up for a Medicare Advantage (Part C) plan, you can choose different plan types: Medicare HMO or Medicare PPO. Both types of plans offer network and cost options. Find out more about the difference so you can select the one that best fits your budget and healthcare needs.

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What Is Medicare PPO (Preferred Provider Organization)?


A Medicare PPO is a type of plan that allows you to use doctors and hospitals both in and out of network without a referral. Although you can seek coverage outside of your plan's network, you may pay less when receiving in-network care. Anthem Medicare Advantage PPO is a Part C Medicare PPO plan that gives you the flexibility to work with any doctor or specialist, in or out of network, no referrals needed.



What Is Medicare HMO (Health Maintenance Organization)?


A Medicare HMO is a type of plan in which you must get most of your care from a specific network of doctors and hospitals – unless it is an emergency. You may also need a referral from a primary doctor to see a specialist. Anthem Medicare Advantage HMO is a Medicare HMO that has all the benefits of a Medicare Advantage plan with access to our leading network of quality doctors.



Is Medicare PPO Or HMO Better?


Each type of plan offers different types of coverage based on cost and networks, so the best plan for you depends on your budget and your doctor preferences.

Medicare PPO is a better choice if:

Medicare HMO is a better choice if:

  • You are looking for more flexibility in the doctors you see.
  • You don't mind paying a little bit more for a plan with a larger network.
  • You'd rather see a specialist or receive medical tests without a referral.
  • You like lower costs and don't mind receiving care from a specific network of doctors.
  • Doctors you would like to see are participating in the network.
  • You like having a primary care physician coordinate all of your care and provide referrals for other specialists and other tests.

Are PPO And HMO Offered Under Original Medicare?


PPO and HMO plans are available as Medicare Advantage plans only through private insurers like Anthem. If you are enrolling in Medicare for the first time, you'll have to sign up for Original Medicare first. You can then choose a Medicare Advantage HMO or PPO plan that works for you.



The Difference Between HMO Vs. PPO Medicare Costs

HMO Medicare Costs

PPO Medicare Costs

HMO plan costs tend to be lower than PPO plans as long as you receive care within the network. Choosing doctors outside of the network or seeing a medical specialist without a referral from your primary care doctor will cost more.

PPO plans tend to have somewhat higher costs than HMO plans, but they generally have larger networks. You also have the flexibility to see doctors out of the network at an additional cost.

Prescription Drug Coverage By Plan Type


Depending on the plan, both PPO and HMO plan types can offer medical and prescription drug coverage for an all-in-one plan. If you take medications regularly, make sure to find a plan that provides that coverage.



Can I Switch From Medicare HMO To Medicare PPO?


Yes, you can change your plan type during the Medicare Annual Enrollment Period, which is October 15 to December 7. You can also change your Medicare Advantage plan type during the Medicare Open Enrollment Period, which is January 1 to March 31. In addition, you may have a Special Enrollment Period based on certain life events that affect your coverage. This Special Enrollment Period lets you switch to a different Medicare Advantage plan if you qualify.



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Anthem Blue Cross is an HMO plan with a Medicare contract. Anthem Blue Cross Life and Health Insurance Company is an LPPO plan with a Medicare contract. Anthem Blue Cross is an HMO SNP plan with a Medicare contract and a contract with the California Medicaid program. Enrollment in Anthem Blue Cross, Anthem Blue Cross Life and Health Insurance Company depends on contract renewal. 


Out-of-network/non-contracted providers are under no obligation to treat Medicare Advantage Plan members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.