HMO or PPO: start with how you get care

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.

Go straight to the source

• Medicare HMO plans
• Medicare PPO plans
• Understanding Medicare Advantage

Sources checked September 28, 2026. General education, not a coverage determination or medical advice. Plan terms, eligibility, and state rules can vary. How we approach education