Medicare Preferred Provider Organizations (PPOs)

Comparison: PPOs, HMOs, and Original Medicare

Consider these differences between a Medicare Advantage PPO, an HMO, and Original Medicare to make sure you get the best health coverage for your needs.

Last Updated: April 2, 2025

There are several differences in costs and coverage among Original Medicare Original Medicare, also known as Traditional Medicare, is the fee-for-service health insurance program offered through the federal government, which pays providers directly for the services you receive. Almost all doctors and hospitals in the U.S. accept Original Medicare. , Preferred Provider Organizations (PPOs), and Health Maintenance Organizations (HMOs). The table below compares these three types of Medicare plans. If you are interested in joining a PPO, make sure to speak to a plan representative for more information.

Original Medicare

Medicare PPO

Medicare HMO

See any provider and use any facility that accepts Medicare (participating or non-participating)

See any provider, but generally pay more when seeing out-of-network providers

Visit doctors anywhere in the U.S.

Visit doctors anywhere in the U.S., but generally pay more when seeing out-of-network providers

Visit doctors only in your plan’s service area, except in emergencies or when care is urgently needed

Do not need referrals for specialists

Do not need referrals for specialists

Typically need referrals for specialists

Does not cover vision, hearing, or dental services

May cover additional services, including vision, hearing, and dental (additional benefits may increase your premium or other out-of-pocket costs)

May cover additional services, including vision, hearing, and dental (additional benefits may increase your premium or other out-of-pocket costs)

Sign up for a stand-alone prescription drug plan (Part D)

In most cases, plan provides prescription drug coverage (you may be required to pay higher premium)

In most cases, plan provides prescription drug coverage (you may be required to pay higher premium)

Charged for standardized Part A and Part B costs (premiums and other cost-sharing for Part D vary depending on plan)

Generally charged higher monthly premiums than in HMOs (usually pay a copayment for in-network care and a coinsurance for out-of-network care)

Cost-sharing varies depending on plan

No out-of-pocket limit

Annual out-of-pocket limits for in-network care and combined in-network and out-of-network care (varies by plan)

Annual out-of-pocket limit for in-network care (maximum is $9,350 in 2025)

Remember, if you enroll in an HMO or PPO you cannot sign up for stand-alone prescription drug coverage. Make sure your plan provides Part D Part D, also known as the Medicare prescription drug benefit, is the part of Medicare that provides prescription drug coverage. Part D is offered through private companies either as a stand-alone plan, for those enrolled in Original Medicare, or as a set of benefits included with a Medicare Advantage Plan. coverage if you need it.

If you have Original Medicare, you also have the choice to purchase a supplemental insurance policy, or Medigap. Medigap plans cover Medicare cost-sharing Cost-sharing is the portion of medical care costs that you pay yourself, such as a copayment, coinsurance, or deductible, if you have health insurance coverage. See also: Out-of-Pocket Costs. and offer other benefits, but charge an additional premium A premium is an individual’s monthly payment to a Medicare or other health insurance plan for coverage. . You cannot enroll in a Medigap plan if you have Medicare Advantage Medicare Advantage, also known as Part C, Medicare Private Health Plan, or Medicare Managed Care Plan, allows you to get Medicare coverage from a private health plan that contracts with the federal government. All Medicare Advantage Plans must offer at least the same benefits as Original Medicare (Part A and Part B), but can do so with different rules, costs, and coverage restrictions. Plans typically offer Part D drug coverage as part of Medicare Advantage benefits. Medicare Advantage Plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS) plans, Special Needs Plans (SNPs), and Medicare Medical Savings Accounts (MSAs). .

Glossary Terms

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