Medicare Advantage HMO vs. PPO: What's the Difference?

Last updated October 2026

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The Short Answer: Neither plan type is better for everyone. Medicare Advantage HMOs usually have lower costs but require you to use in-network providers and often need referrals to see specialists. PPOs cost more but let you see out-of-network providers and usually skip referrals. The right fit depends on your doctors, budget, and how much flexibility you want.

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HMO vs. PPO at a glance

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What is a Medicare Advantage HMO?

An HMO plan works with a set network of doctors and hospitals. You usually choose a primary care provider who coordinates your care and refers you to specialists when needed. Care outside the network is generally not covered unless it is an emergency or urgent care.

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An HMO may be a good fit if:

• Your doctors and preferred hospital are in the plan's network
• You like having one primary care provider guide your care
• Keeping monthly costs and copays low is a priority
• You get most of your care close to home

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What is a Medicare Advantage PPO?

A PPO plan also has a network, but it gives you more freedom. You can see providers outside the network, though you will usually pay more to do so. You typically do not need a referral to see a specialist.

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A PPO may be a good fit if:

• You want to keep a doctor or specialist who is not in any HMO network you are considering
• You spend part of the year away from home
• You prefer to see specialists without a referral
• You are comfortable paying more for flexibility

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Questions to ask before you choose

1. Are my primary care provider, specialists, and hospital in the network for 2027?
2. Do I need referrals, and how does that process work?
3. What will I pay in premiums, copays, and the yearly out-of-pocket maximum?
4. Are my prescriptions covered?
5. What happens if I need care while traveling?

Hopscotch accepts both HMO and PPO plans from all plans we accept in 2027. See which plans we accept in 2027.

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Frequently asked questions

Is an HMO or PPO better for seniors?
Neither is better for everyone. HMOs tend to cost less but have stricter network rules. PPOs cost more but offer more flexibility. The best choice depends on your doctors, health needs, and budget.

Do Medicare Advantage HMOs require referrals?
Many do. You usually need a referral from your primary care provider to see a specialist. Check your plan's rules, since some HMOs allow certain visits without a referral.

Can I see any doctor with a PPO?
You can see out-of-network doctors who agree to treat you, but you will usually pay more than you would for in-network care.

Are there other types of Medicare Advantage plans?
Yes. Special Needs Plans (SNPs) serve people with certain conditions or with both Medicare and Medicaid, and some areas have Private Fee-for-Service (PFFS) plans. Availability varies by county.

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Where to get free, unbiased Medicare help

If you want help comparing plans side by side, these free resources are not tied to any insurance company:

• Your Hopscotch care team can connect you with a trusted broker who can help you review your Medicare plan options. Call your care team to schedule an appointment with a broker.
• NC SHIIP (Seniors' Health Insurance Information Program) offers free, unbiased Medicare counseling. Call 1-855-408-1212 or visit ncdoi.gov/shiip.
• Medicare: Call 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048) or use the Plan Finder at Medicare.gov.
• Your plan: Call the member services number on the back of your insurance card with questions about your own coverage.

Hopscotch Primary Care is a primary care provider, not an insurance company or agent. We do not sell, recommend, or endorse any Medicare plan. This article is for general education and is not insurance, legal, or medical advice. Plan details, costs, and availability vary by plan and location and can change each year.