Blog / Medicare Advantage

HMO or PPO: which Medicare Advantage plan type should I choose?

The difference comes down to what happens when you need a doctor outside the network. Here is how to decide before you need one.

Updated August 17, 2026 · 3 min read

Most Medicare Advantage plans are one of two types, and the difference between them shows up exactly when you least want a surprise.

HMO

• You use the plan's network. Care outside it is generally not covered at all, except emergencies and urgent care.
• You choose a primary care physician who coordinates your care.
• You usually need a referral before seeing a specialist.
• Premiums and copays are typically lower.
• The most common plan type, and the most common zero premium type.

The strength of an HMO is cost. The risk is that going outside the network is not a matter of paying more, it is a matter of paying everything.

PPO

• You can see out of network providers, at a higher cost share.
• Usually no referral needed to see a specialist.
• Premiums and copays are typically higher.
• Two out of pocket maximums: a lower in network figure and a higher combined figure.

The strength of a PPO is flexibility. You pay for it every month whether you use it or not.

The question that actually decides it

Not which is better. How likely are you to need care outside the network, and what happens if you do?

• If all your doctors are local, in network, and you rarely leave the area, an HMO is usually the better value.
• If you split time between states, travel often, or see a specialist in San Antonio or Houston, a PPO earns its cost.
• If you have a condition that might require a referral to a specialized center, a PPO is worth serious consideration.

What both types share

• Emergency and urgent care are covered anywhere in the United States, including out of network. Do not hesitate to go to the nearest emergency room.
• Both must cover everything Original Medicare covers.
• Both have an annual out of pocket maximum.
• Both use prior authorization on many services.

A note on this area

Networks in South Texas are deep, with the major local systems well represented. That is a real reason HMO plans work well for a lot of people here and why so many local beneficiaries are on them.

The people who should think harder are the ones who travel, who spend part of the year elsewhere, or who cross the state for specialty care. See how Advantage plans handle travel.

Check before you enroll

1. List your doctors, your specialists and the hospital you would want to use.
2. Call each billing office and ask about the exact plan name for the coming year.
3. Ask the plan how out of network care is handled and what the combined maximum is if it is a PPO.
4. Ask whether a referral is required and how long authorizations typically take.

See the full guide to checking your doctors.