Medicare HMO vs. PPO: What is the Difference? | Anthem (2024)

FAQs

Medicare HMO vs. PPO: What is the Difference? | Anthem? ›

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.

HMO plans typically have lower monthly premiums. You can also expect to pay less out of pocket. PPOs tend to have higher monthly premiums in exchange for the flexibility to use providers both in and out of network without a referral. Out-of-pocket medical costs can also run higher with a PPO plan.

Doctors often prefer PPOs because they offer greater reimbursem*nt rates compared to HMOs and have less administrative paperwork. Is a PPO a good thing? For many, a PPO's flexibility and coverage make it a favorable choice, but it comes with higher premiums.

Compared to PPOs, HMOs cost less. However, PPOs generally offer greater flexibility in seeing specialists, have larger networks than HMOs, and offer some out-of-network coverage.

In some cases, you'll have a higher share of costs when you see an out-of-network doctor. In other cases, you're not covered at all if you go out of network. This is particularly important if you travel a lot because Medicare Advantage plans generally don't provide out-of-state coverage.

PPO plans are typically more expensive than other plan types. Not only will your plan premium be higher, but you'll also have to meet your annual deductible before your insurance company kicks in its share.

HMO plans might involve more bureaucracy and can limit doctors' ability to practice medicine as they see fit due to stricter guidelines on treatment protocols. So just as with patients, providers who prefer a greater degree of flexibility tend to prefer PPO plans.

PPO plans typically require higher monthly payments in exchange for increased flexibility. With a PPO, you do not need to maintain a primary care physician and can see a different doctor of your choice at any time, including specialists. This also means when you are traveling, you can receive care wherever you are.

HMO plans tend to be more affordable with lower monthly premiums and lower out-of-pocket costs — unless you see an out-of-network provider. You will also likely not have to file a claim, since you are seeing physicians in your network and your insurance provider will work with your healthcare providers directly.

What are 2 advantages of choosing the PPO? ›

PPO health insurance allows you more freedom to get care anywhere, while a POS plan may allow out-of-network care but demand a primary care referral. A PPO health insurance plan doesn't typically require that you name a primary care provider to oversee your care.

Network restrictions are another common reason why beneficiaries leave their Medicare Advantage plans. With Medicare Advantage plans, staying within your policy's network is key to paying the lowest possible costs for health services. Going out of your network could mean high fees or no coverage.

The two key issues that led to the decision to stop working with Advantage plans, he said, were the rates insurance companies were willing to pay, and the tendency of sicker patients to seek treatment at top-notch medical centers such as those run by Scripps.

What's the biggest disadvantage of Medicare Advantage? The biggest disadvantage of Medicare Advantage plans is that they limit your choice of doctors and medical offices.

With PPO insurance, you have a wider network of providers, and you can choose to see a doctor who is not in the network. You'll typically pay less to see in-network providers, but the plan will pay part of the cost even if you go outside of the network.

An HMO Plan is a type of Medicare Advantage Plan that generally provides health care coverage exclusively from doctors, other health care providers, or hospitals in the plan's network (except emergency care, out-of-area urgent care, or temporary out- of-area dialysis).

PPO health insurance allows you more freedom to get care anywhere, while a POS plan may allow out-of-network care but demand a primary care referral. A PPO health insurance plan doesn't typically require that you name a primary care provider to oversee your care.