Medicare Advantage HMO PPO Plans

How the network rules differ

An HMO generally uses its network, with exceptions for emergencies, urgent care and out-of-area dialysis. Some HMO-POS plans cover certain out-of-network services. A PPO permits covered out-of-network care, usually at a higher cost. Medicare compares plan types.

HMOs usually require a primary care doctor and specialist referrals; PPOs generally do not. Either type can require prior authorization. Check each rule for the service you need.

Check the provider, location and plan year

• Give the plan the provider’s full name and practice address.
• Confirm the exact plan, not just whether the office accepts the insurer.
• Ask about hospitals, outpatient sites and specialists separately.
• For PPO out-of-network care, confirm the provider will treat you and what you could owe.

For example, if you see a specialist at two offices, ask about both locations. If you spend several months away from home, describe the routine care you need while traveling and request the plan’s coverage rules in writing.

Compare the full budget

Build a side-by-side estimate using the same care needs for each plan. Include premiums, deductibles, office and hospital cost sharing, prescription spending and applicable medical out-of-pocket limits. A low premium alone does not show which option costs less over a year.

• What would several specialist visits cost?
• How are outpatient procedures and hospital stays charged?
• What is the medical spending limit, and how does out-of-network care count?
• Which services require authorization or have visit limits?

Planning for 2027 prescription costs

CMS lists a $700 standard Part D deductible and a $2,400 annual out-of-pocket threshold for 2027. Individual plans may have a lower deductible. These figures describe Part D, not a limit on all Medicare spending. See CMS Table V-2.

Ask for a full-year drug estimate using exact medications, doses and pharmacies. Budget separately for premiums and noncovered drugs. Confirm the published Part A and Part B amounts for the coverage year before making a budget.

Drug coverage and additional benefits

Most HMO and PPO Medicare Advantage plans include Part D. If you want drug coverage, choose an HMO or PPO that includes it; you generally cannot add a standalone Part D plan to these plans. Verify the exact enrollment arrangement before making a change.

For dental, vision, hearing or other extra benefits, request the annual allowance, covered services, provider restrictions and eligibility conditions. Treat a benefit as unconfirmed until it appears in the correct plan-year documents.

Consider the Original Medicare route too

If you are considering Medicare Supplement insurance, its six-month open enrollment period begins when you are 65 or older and enrolled in Part B. Later applications may involve underwriting unless a protection applies. Review Medigap timing and rights.

Enrollment timing

Medicare Annual Enrollment runs October 15–December 7, 2026, for January 1, 2027 coverage. Other enrollment opportunities depend on your circumstances. Check Medicare’s enrollment guidance.

Before replacing coverage, confirm your eligibility, application deadline and effective date. An enrollment opportunity does not mean every type of insurance is available without underwriting.

Bring the comparison back to your needs

Write down the two or three issues you most want a plan to solve. Review those issues against each option’s documents, then confirm any unresolved point before submitting an application.

Explore Medicare Advantage plan types or ask James O’Neal for a review.

Important disclosures

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your State Health Insurance Assistance Program to get information on all of your options.

O’Neal Insurance Group is not affiliated with or endorsed by the United States government or the federal Medicare program. Insurance services are provided by licensed agents in states where services are offered. Benefits, costs, networks, formularies and availability vary by plan, location and year. Confirm current plan documents before enrolling.