HMO, in general
An HMO usually requires you to use doctors and hospitals in the plan network, except in an emergency. A primary-care doctor and referrals to specialists are common. Rules vary by plan. Read the Evidence of Coverage.
What an HMO usually will not pay for
These are the limits that surprise people. They are not the same on every HMO. The Evidence of Coverage and the doctor’s office are the check. If the HMO does not cover the visit, Original Medicare does not pay the rest while you are in that plan. Write the answers down with the questions to ask the doctor’s office.
- A doctor who takes Original Medicare, if that doctor is not on this HMO.
- A specialist who is on the plan, but not in your medical group.
- A specialist visit with no referral, when that plan requires one.
- A test or hospital stay the plan has not approved, when approval is required.
- Routine care outside the plan’s service area. Emergency care is the exception.
- An HMO-POS visit at the in-network price. Some out-of-network care may be paid, usually at a higher cost.
PPO, in general
A PPO usually lets you see out-of-network providers at a higher cost. Referrals may not be required. The plan can still require approval before it pays for a hospital stay, a test, or other care. Out-of-network bills can be large. A PPO is not Original Medicare, and Original Medicare does not pay the part the PPO leaves unpaid.
HMO and PPO, side by side
Neither type is automatically better. In Los Angeles County for 2027, CMS lists 97 HMO plans and 6 PPO plans. There are also 21 HMO-POS plans, which are HMOs with a limited out-of-network option. The HMO premium in that file is often $0. A lower premium does not mean the HMO includes your doctors.
- Doctors. An HMO generally pays only its network, except in an emergency. A PPO may also pay out-of-network doctors, usually at a higher cost.
- Medical group. Many Los Angeles HMOs add a second gate: your medical group or IPA. A PPO can still charge more, or pay nothing, for a doctor outside its network.
- Referrals. HMOs often require one before a specialist. PPOs often do not. Check the Evidence of Coverage either way.
- Approval. Both types can require the plan to approve a test, a hospital stay, or equipment before they pay.
- Travel. Routine care is usually limited to the plan’s service area. A PPO does not give you every doctor in the country.
- If the plan will not pay. Original Medicare does not pay the rest on either an HMO or a PPO.
The meaning of HMO-POS
HMO-POS means an HMO with a point-of-service option. Inside the network, it works like an HMO. The extra word means the plan may pay for some doctors or hospitals that are not in the network. That permission is not the same on every plan. In Los Angeles County for 2026, CMS lists 24 HMO-POS plans. The premium is often $0. The $0 does not tell you what you would pay to go outside the network. The plan list shows in-network costs. The out-of-network price and any dollar cap are in the Evidence of Coverage.
- In network, you still use the plan’s doctors. A medical group, a referral, or an approval can still apply.
- Out of network, the plan may pay only for certain services, and it may still require a referral or an approval.
- That visit usually costs more than the same visit in network.
- The plan can cap how much out-of-network care it will pay. The in-network maximum does not automatically cap those bills.
- Emergency care is covered under the plan’s emergency rules. That is separate from the point-of-service benefit.
- An HMO-POS is not a PPO, and it is not Original Medicare. If the plan will not pay, Original Medicare does not pay the rest.
This is not Medigap
Medigap is not an HMO or PPO. It works with Original Medicare and typically does not use an Advantage-style network. Confusing those structures is a common source of surprise medical bills.
ZIP code still decides what exists
HMO and PPO products available to you depend on ZIP code. In Los Angeles County for 2027, CMS lists 97 HMO plans, 21 HMO-POS plans, and 6 PPO plans. A PPO is uncommon there, and it still is not Original Medicare. Medisure Agency does not offer every plan in your area. See the 2027 plan list, or the complete list on Medicare.gov, at 1-800-MEDICARE (TTY 711), or through California HICAP at 1-800-434-0222.
Common questions
- Is an HMO-POS the same as a PPO?
- No. An HMO-POS is an HMO that may pay for some out-of-network care. The visits it will pay, and what you owe, are in that plan’s Evidence of Coverage. A PPO is a different plan type. Neither one is Original Medicare.
- If my HMO will not pay, does Original Medicare pay the rest?
- No. While you are in a Medicare Advantage plan, Original Medicare does not step in and pay a routine visit the HMO denied. Emergency care has its own rules. Confirm the visit with the office and the plan.
- Is a PPO the same as Original Medicare?
- No. A PPO is a type of Medicare Advantage network. Original Medicare is Parts A and B, accepted by providers who take Medicare.
- Which is better — HMO or PPO?
- Neither is automatically better. Doctors, drugs, travel, and cost-sharing all matter. This website does not pick a plan.
My Medicare Checkup
Answer a few questions about your ZIP code, what matters about cost and doctors, and where you get care. The summary shows the questions those answers raise. Confirm each one with the office, the plan, or Medicare.gov. A listing in a directory, or the name of a plan, does not show whether a doctor is in the network, whether a prescription is covered, or what you would pay this year.
Start My Medicare CheckupYou will get a summary of the questions to verify. You can also talk it through with Alan.
For the other pages on this topic, open the Keeping your doctors guide.