A Medicare Advantage HMO usually requires you to use its provider network and get referrals to specialists. A PPO generally allows more care outside its network, but you may pay more for it. Both must cover the medically necessary services Original Medicare covers.

How Medicare Advantage HMOs Work

An HMO generally requires you to use doctors, hospitals, and other providers in the plan's network, except for emergency care, out-of-area urgent care, and temporary out-of-area dialysis. Most HMOs require a primary care doctor and referrals for specialist care.

Some HMO Point-of-Service plans cover selected out-of-network services at a higher cost. Do not assume ordinary HMO care is covered outside the network.

How Medicare Advantage PPOs Work

A PPO has a preferred network but generally covers eligible care outside that network at a higher cost. PPOs usually do not require you to select a primary care doctor or get a referral to a specialist.

Before using an out-of-network provider, confirm that the provider will treat you and that the plan considers the service covered and medically necessary.

Which May Fit Better?

Compare the same doctors and expected services under the actual plans. An HMO does not automatically cost less or coordinate care better. With a PPO, an out-of-network doctor may still decline to treat you.

Hypothetical specialist example: an HMO and a PPO both cover your specialist in-network. Six visits at a $35 HMO copay cost $210; six at a $50 PPO copay cost $300. If the PPO instead charges $90 for that specialist out-of-network, those visits cost $540. These made-up figures leave out premiums, deductibles, tests, and other care. A different plan’s prices could reverse the comparison.

For time away from home, check routine-care coverage at the destination. Emergency coverage alone does not answer that question.

Ask the specialist’s office about the exact plan and location, then verify the benefit and cost with the plan. Compare the in-network limit and the combined limit for in- and out-of-network care if you expect to use both.

Medicare policy sources last checked: October 8, 2026.