HMO or PPO? Which Medicare Advantage (Part C) plan is right for you?

Enroll in an all-in-one Medicare Advantage plan and you will still get all the benefits you’d receive with Original Medicare. What’s different is that a private insurance company provides you with Medicare Part A and Part B benefits versus the federal government, and often includes additional coverage such as prescription drugs, dental, vision, hearing, even a fitness membership.

When you’re turning 65, there are two popular types of Medicare Advantage plans to choose from: HMO (Health Maintenance Organization), and PPO (Preferred Provider Organization). In 2020, over 24 million people are projected to choose a Medicare Advantage plan.¹

 Now let’s take a look at the differences between the two types of plans so you’ll have a better understanding when you’re ready to decide.  

Medicare Advantage HMO: low to no monthly premium, coordinated care.

With an HMO, you’ll choose a primary care physician (PCP) from the plan’s network of providers. Your PCP will coordinate all your health services with your care team and any specialists you need to see (referrals often required). Think of your PCP as a healthcare advocate helping you to be in your best health.

Since it’s a type of managed care plan, you can also expect lower monthly premiums, affordable copays and/or coinsurance, and a maximum out-of-pocket cost that won’t break your budget. Paperwork is kept to a minimum, too.  

Today’s Medicare Advantage HMO plans have comprehensive benefits, including:

• Coverage for preventive healthcare (e.g., annual physical exam, cancer screenings)
• Routine and major medical and hospital services (e.g., sick visits, lab tests, X-rays, surgery)
• Prescription drug benefits (Medicare Part D) with tiered copays for generic and brand-name drugs
• Access to senior-focused care at myGeneration Senior Clinics for select plans²
• Emergency coverage when traveling outside Nevada

Medicare Advantage PPO: higher monthly premium, greater provider freedom.

PPOs are also a type of managed care plan that provide comprehensive benefits, but at a higher monthly premium than an HMO. Why do they cost more? You’re paying for flexibility. PPO plans don’t require you to choose a primary care physician (PCP) or get referrals to see specialists. There’s also typically a much larger provider network that you can go outside of for your healthcare services. But if you do that, your out-of-pocket costs can really start to add up.

For example, if you see a doctor or go to a hospital in-network, a PPO plan may cover you at 100%. Go outside the network and a PPO plan may only pay 80% or less of the bill — or sometimes not at all. There could also be a separate out-of-network deductible. You may even need to pay the out-of-network provider yourself, and then file a claim to get reimbursed.  

Which kind of plan works best for you?

The simplest way to choose a Medicare plan is to think about your health needs and your lifestyle. If you like having the freedom to see any doctor or specialist, use healthcare services on a regular basis, and don’t mind paying more, then consider a Medicare Advantage PPO plan.

On the other hand, if you’re healthy, don’t go to the doctor very often, and like saving on your healthcare, then a Medicare Advantage HMO plan may be your best option. Another big advantage for select plans is you’ll get access to myGeneration Senior Clinics — providing senior-focused care in nearly 30 locations across Southern Nevada.²

Make the choice for a healthier you! Sign up for a Medicare Advantage HMO plan and myGeneration Senior Clinics. Call us at 702-852-9000 today.

¹Centers for Medicare & Medicaid Services

²Not all Medicare Advantage plans accepted. Call or click for details.