Your coverage
HMO or PPO: start with how you get care
The letters describe access to care. The useful question is what that means for your doctors, your routine, and your budget.
Medicare Advantage HMOs generally use a network and require specialist referrals. PPOs generally allow covered out of network care at a higher cost and do not require specialist referrals.
How an HMO usually works
You generally use the network, except for emergency care, out of area urgent care, and temporary out of area dialysis. Most HMOs require a primary care doctor and specialist referrals. Some HMO POS plans allow certain out of network services at higher cost.
How a PPO usually works
You usually pay less in network. Covered out of network services generally cost more. Confirm arrangements and coverage with the plan before non emergency out of network care. PPOs generally do not require a primary care doctor or specialist referral.
A referral is not prior authorization
A referral directs you to another provider. Prior authorization is the plan’s approval for a service. One does not necessarily satisfy the other. Check the exact plan’s requirements before scheduling care.
Compare the plan, not just the letters
List regular doctors and your preferred hospital. Check each exact plan, including drug coverage and in network and out of network costs. Neither label determines the right choice for everyone.
Make it useful
Your next step checklist
Use this here, or print it for your next conversation. Your checks stay on this page only.