Medicare Advantage HMO vs PPO: How the Two Plan Types Differ in Utah

Medicare Advantage HMO vs PPO comes down to networks and referrals. With an HMO, you generally must use the plan's network (except emergency care, out-of-area urgent care and temporary out-of-area dialysis), you usually choose a primary care doctor, and you usually need a referral to see a specialist. With a PPO, you can generally go out of network for covered services, usually at a higher cost, and you don't need a primary care doctor or referrals.

Source: Medicare.gov: Compare types of Medicare Advantage Plans

Key takeaways

Both are Medicare Advantage (Part C): Medicare-approved plans from private companies that must cover all the medically necessary services Original Medicare covers.
Network: an HMO generally requires in-network care. A PPO lets you go out of network for covered services, usually at a higher cost.
Referrals: an HMO usually requires a primary care doctor and referrals to specialists. A PPO doesn't.
Drugs: most HMOs and PPOs include drug coverage. If yours doesn't, you can't join a separate Medicare drug plan.
Yearly limit: every plan has an in-network out-of-pocket limit. A PPO also has a combined in- and out-of-network limit.

Want to see how an HMO and a PPO would work with your doctors? Book a phone or video call with our Utah team.

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This guide compares the two most common Medicare Advantage plan types, side by side, using Medicare.gov's rules. We don't show prices or recommend a plan type; we explain how each one works so you can match it to your doctors and how you get care.

New to Medicare Advantage? Start with What is Medicare Part C? and come back here.

HMO vs PPO: the side-by-side chart

Medicare Advantage HMO vs PPO chart from Medicare.gov: an HMO generally requires in-network care except emergency care, out-of-area urgent care and temporary out-of-area dialysis, usually requires a primary care doctor and requires referrals to specialists. A PPO covers out-of-network care for covered services, usually at a higher cost, and doesn't require a primary care doctor or referrals. Both usually include drug coverage, both may require prior authorization for certain services, and both have a yearly out-of-pocket limit; a PPO also has a combined in- and out-of-network limit.

	HMO (Health Maintenance Organization)	PPO (Preferred Provider Organization)
Doctors and hospitals	Generally in network only, except emergency care, out-of-area urgent care and temporary out-of-area dialysis	In network, or out of network for covered services, usually at a higher cost
Primary care doctor	Usually required	Not required
Referral to see a specialist	Yes, in most cases (some services, like yearly mammograms, don't need one)	No
Drug coverage (Part D)	Usually included	Usually included
Emergency and urgent care	Covered, in or out of network	Covered, in or out of network
Monthly premium	Many charge a premium in addition to the Part B premium	Many charge a premium in addition to the Part B premium
Prior authorization	May be needed for certain services	May be needed for certain services
Yearly out-of-pocket limit	In-network limit	In-network limit and a combined in- and out-of-network limit

Sources: Medicare.gov: Compare types of Medicare Advantage Plans · HMOs · PPOs

How a Medicare Advantage HMO works

An HMO is a type of Medicare Advantage plan offered by a private insurance company. You generally must get your care from doctors, other providers and hospitals in the plan's network, except emergency care, out-of-area urgent care and temporary out-of-area dialysis (Medicare.gov).

Primary care doctor: in most HMOs, you choose one.
Referrals: in most cases, you need a referral to see a specialist. Some services, like yearly screening mammograms, don't need one.
Out of network: if you get care outside the network, you may have to pay the full cost, except for the emergency and urgent care situations above.
HMO Point-of-Service (HMO-POS): some HMOs let you get some services out of network for a higher copayment or coinsurance.

How a Medicare Advantage PPO works

A PPO is also a Medicare Advantage plan offered by a private insurance company. It has a network of doctors, other providers and hospitals. You pay less when you use the network, and you can generally go to out-of-network providers for covered services, but you'll usually pay more (Medicare.gov).

Primary care doctor: not required.
Referrals: not required to see a specialist.
Out of network: you can use out-of-network providers that participate in Medicare or accept assignment. Before you do, contact the plan to make sure the service is medically necessary and covered.
Emergency and urgent care: always covered.

What happens when you see a doctor outside the plan's network: with an HMO, you may pay the full cost, except for emergency care, out-of-area urgent care and temporary out-of-area dialysis; with an HMO Point-of-Service plan, some services may be covered out of network at a higher cost; with a PPO, covered services are covered out of network, usually at a higher cost. Emergency and urgent care are covered in every case.

What's the same with an HMO and a PPO

Covered services: both must cover all the medically necessary services Original Medicare covers. If you need hospice care, Original Medicare covers it even while you're in a Medicare Advantage plan.
Drug coverage: usually included. If you join an HMO or PPO that doesn't offer drug coverage, you can't join a separate Medicare drug plan (Medicare.gov).
Prior authorization: you'll typically need approval from your plan before it covers certain services or supplies. If your plan approves a treatment, the approval must be valid for as long as the treatment is medically necessary.
Cost protections: neither plan can charge more than Original Medicare for certain services, like chemotherapy, dialysis and skilled nursing facility care.
Yearly out-of-pocket limit: every plan has one for covered Part A and Part B services. For 2027 plans, CMS allows an in-network limit of up to $9,850 and a combined limit of up to $14,800. Many plans set lower limits (CMS, CY 2027 MOOP limits). For 2026 the limits were $9,250 and $13,900. Plan premiums, your Part B premium, Part D drug costs and care the plan doesn't cover don't count toward the limit.
Your Part B premium: you keep paying it with either plan type ($202.90 a month for most people in 2026, per CMS).
Medigap: Medigap can't be used with any Medicare Advantage plan. Learn about the other path in What is Medigap?

Compare HMO and PPO rules for your situations

Pick the situations that matter to you. The tool shows how an HMO and a PPO usually handle each one, from Medicare.gov's rules, and marks where they're the same or different.

How to compare an HMO and a PPO in your county

Questions to ask when comparing a Medicare Advantage HMO and PPO: are my doctors and hospitals in the network, do I need referrals to see my specialists, what would I pay out of network, which services need prior authorization, are my prescriptions covered at my pharmacy, what are the in-network and combined out-of-pocket limits, and how does coverage work when I travel.

List your doctors and hospitals

Check whether each one is in the plan's network for next year. With an HMO, this matters most, because out-of-network care is generally not covered except in emergencies and urgent care away from home.

List your prescriptions and pharmacy

Check that each drug is on the plan's drug list and how your pharmacy fits the plan.

Ask about referrals and prior authorization

Ask whether you'd need a referral to see your specialists and which services need approval first.

Compare the yearly out-of-pocket limits

Look at the in-network limit, and for a PPO, the combined in- and out-of-network limit.

Think about travel and time away from home

If you spend part of the year outside the plan's service area, ask how the plan covers care there.

Compare costs in Medicare Plan Finder

Plans and plan types vary by Utah county. Compare premiums, copays and deductibles for plans in your county in Medicare Plan Finder.

When can you join or change a Medicare Advantage plan?

When you're first eligible: during your Initial Enrollment Period around your 65th birthday. See turning 65 in Utah and Medicare enrollment dates.
Every fall: during Medicare Open Enrollment, October 15 to December 7, you can join, switch or drop a Medicare Advantage plan. Coverage starts January 1.
January to March: if you're already in a Medicare Advantage plan, the Medicare Advantage Open Enrollment Period (January 1 to March 31) lets you make one change.

For the Utah picture, see Medicare Advantage plans in Utah. To weigh Medicare Advantage against Original Medicare with a Medigap policy, see Medicare Advantage vs. Medicare Supplement or compare Utah Medicare Advantage plans with Original Medicare.

How our team helps

We're Boo Insurance Services, a licensed independent Medicare agency in Draper, licensed since 2014. We can show you options from more than one company. We've helped 1,000+ Utahns with Medicare and have 170+ 5-Star Google Reviews. Appointments are by phone or video, anywhere in Utah. You won't pay us a fee. Insurance companies pay us when you enroll, and that doesn't change your plan's benefits, coverage or premium. Before we talk about specific plans, you'll confirm what we'll discuss with a short Scope of Appointment form, which Medicare rules require. You decide, with no obligation.

Bring your list of doctors and prescriptions, and we'll walk through HMO and PPO plans in your county by phone or video.

Call 801-255-5341 Book a phone or video call

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Frequently asked questions

What is the main difference between a Medicare Advantage HMO and PPO?

An HMO generally requires you to use its network, except for emergency care, out-of-area urgent care and temporary out-of-area dialysis, and usually requires referrals to see specialists. A PPO lets you go out of network for covered services, usually at a higher cost, and doesn't require referrals.

Do I need a referral with a Medicare Advantage PPO?

No. Medicare.gov says you don't need a referral to see a specialist in a PPO, and you don't need to choose a primary care doctor.

Can I see a doctor outside the network with a Medicare Advantage HMO?

Generally not, except for emergency care, out-of-area urgent care and temporary out-of-area dialysis. If you get other care out of network, you may have to pay the full cost. Some HMO Point-of-Service plans cover some out-of-network services at a higher cost.

Do Medicare Advantage HMOs and PPOs include drug coverage?

Usually. Most HMOs and PPOs include drug coverage. If you join one that doesn't, you can't join a separate Medicare drug plan.

Does a Medicare Advantage PPO have an out-of-pocket limit?

Yes. Every Medicare Advantage plan has a yearly limit on what you pay for covered Part A and Part B services in network, and a PPO also has a combined limit for in- and out-of-network services. For 2027 plans, CMS allows up to $9,850 in network and up to $14,800 combined; many plans set lower limits. Once you reach your plan's limit, you pay nothing more for covered Part A and Part B services for the rest of the calendar year. Premiums, Part D drug costs and care the plan doesn't cover don't count toward it.

Do I still pay my Part B premium with an HMO or PPO?

Yes. You keep paying your Part B premium with any Medicare Advantage plan, plus any plan premium.

Can I use a Medigap policy with a Medicare Advantage HMO or PPO?

No. Medigap can't be used with a Medicare Advantage plan. Medigap works only with Original Medicare.

When can I join a Medicare Advantage HMO or PPO?

When you're first eligible for Medicare, and every year during Medicare Open Enrollment, October 15 to December 7. If you're already in a Medicare Advantage plan, the Medicare Advantage Open Enrollment Period, January 1 to March 31, lets you make one change.

Serving Utah residents. We do not offer every plan available in your area. Currently we represent 9 organizations which offer 58 products in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

Related guides

Sources

Medicare.gov, Compare types of Medicare Advantage Plans
Medicare.gov, Health Maintenance Organizations (HMOs)
Medicare.gov, Preferred Provider Organizations (PPOs)
CMS, Medicare Advantage rates and statistics (CY 2027 MOOP limits)
CMS, 2026 Medicare Parts A & B Premiums and Deductibles
Medicare.gov, Medicare Plan Finder

Not connected with or endorsed by the United States government or the federal Medicare program. Fores Boo, licensed independent Medicare agent, NPN 17255694, Boo Insurance Services, 61 W 13490 S Ste 201, Draper, UT 84020.

Last updated: October 21, 2026.