What Type of Medicare Plan You Get When You Receive SSDI

Medicare From SSDI Can Be Either an HMO or a PPO — You Choose

When you become may be able to access for Medicare through SSDI, you do not automatically receive one type of plan. Instead, you are enrolled in Original Medicare (Part A and Part B), and then you decide whether to stay with that or switch to a private plan. If you want an HMO or PPO, you must actively choose one — it is not assigned to you.

Original Medicare itself is neither an HMO nor a PPO. It is a fee-for-service program run by the federal government where you can see any doctor who accepts Medicare, and Medicare pays the provider directly. Many people with SSDI stay in Original Medicare their entire lives. But if you want the structure of an HMO or PPO — lower premiums, coordinated care, or a smaller network — you can enroll in a Medicare Advantage plan, which is where the HMO and PPO options live.

Key Takeaways

You start in Original Medicare (Part A and Part B) when you become may be able to access through SSDI, not in an HMO or PPO.
To get an HMO or PPO, you must enroll in a Medicare Advantage plan, which is a private insurance option that replaces Original Medicare.
HMOs require you to choose a primary care doctor and stay within a network; PPOs let you see any doctor but charge more out of pocket.
You can switch between Original Medicare and Medicare Advantage plans during the annual enrollment period (October 15 to December 7) or if you have a may have access to life event.
Your SSDI income and resources do not change based on which Medicare plan you choose.

How Original Medicare Differs From Medicare Advantage HMOs and PPOs

Original Medicare covers hospital care (Part A) and doctor visits and outpatient services (Part B). You pay a monthly premium for Part B, a deductible when you use services, and coinsurance (a percentage of the cost) after that. You can see any doctor in the country who accepts Medicare — there is no network restriction and no requirement to pick a primary care doctor.

Medicare Advantage plans are sold by private insurance companies and must cover everything Original Medicare covers, but they do it through their own networks and rules. An HMO within Medicare Advantage requires you to choose a primary care doctor, get referrals to see specialists, and use doctors and hospitals in the plan's network (except in emergencies). A PPO within Medicare Advantage lets you see any doctor without a referral, but you pay more if you go outside the network. Both usually have lower or zero monthly premiums than Original Medicare Part B, but higher out-of-pocket costs when you use care.

Medicare Advantage HMOs: Network Limits and Lower Premiums

If you enroll in a Medicare Advantage HMO, you are choosing a specific insurance company's plan, and that plan covers you only when you use doctors, hospitals, and other providers that are part of its network. Going outside the network (except for emergencies or urgent care) means you pay the full cost yourself. You must also designate a primary care doctor, who coordinates your care and must refer you to specialists.

The trade-off is cost: many Medicare Advantage HMOs have zero monthly premiums beyond what you already pay for Part B, and some even return a portion of your Part B premium. Out-of-pocket costs per visit are often lower than Original Medicare as well — for example, a copay of $10 to $15 instead of 20 percent coinsurance. But if you travel frequently, see specialists outside your area, or have established relationships with doctors outside the plan's network, an HMO can be restrictive.

Medicare Advantage PPOs: Flexibility With Higher Out-of-Pocket Costs

A Medicare Advantage PPO gives you more freedom to see doctors outside the plan's network without a referral, but you pay a higher share of the cost when you do. In-network care works like an HMO — you pay a copay and the plan covers the rest. Out-of-network care typically requires you to pay coinsurance (20 to 40 percent of the cost) after you meet a higher deductible.

PPOs appeal to people who want to keep seeing their current doctors even if those doctors are not in a particular plan's network, or who move between states seasonally. The monthly premium is usually higher than an HMO, and your out-of-pocket maximum (the most you pay in a year before the plan covers 100 percent) is also higher. But you have the flexibility to see any doctor and change doctors without waiting for a referral.

When You Can Switch Between Plan Types

You are not locked into your choice. Every year, from October 15 to December 7, there is an open enrollment period during which you can switch from Original Medicare to a Medicare Advantage plan, from one Medicare Advantage plan to another, or from Medicare Advantage back to Original Medicare. Changes take effect on January 1.

If you have a may have access to life event — such as moving out of your plan's service area, losing employer coverage, or becoming newly may be able to access for Medicaid — you may be able to switch outside the annual window. Contact Medicare directly at 1-800-MEDICARE to ask whether your situation qualifies.

How SSDI and Medicaid Interact With Your Medicare Plan Choice

Your choice of Medicare plan does not affect your SSDI cash payment or your work incentives. However, if you are also enrolled in Medicaid (which is common for people with SSDI income), your Medicaid program may have preferred Medicare Advantage plans or may require you to enroll in one. Some states have programs that automatically enroll people in both Medicare and Medicaid into specific plans, though you can usually request a different plan.

If you are considering a Medicare Advantage plan, check with your state Medicaid office to see whether that plan is in your state's network and whether Medicaid will coordinate with it. Medicaid covers costs that Medicare does not — like long-term care, dental, and vision — so the combination matters more than the Medicare piece alone.

Costs You Pay Under Each Plan Type

Original Medicare has a Part B monthly premium (currently $164.90 for most people in 2024, though this varies by income), an annual deductible ($240 in 2024), and then 20 percent coinsurance for most services. You also pay the full cost of services Medicare does not cover, like dental, vision, and hearing aids, unless you buy a separate Medigap or Medicaid plan.

Medicare Advantage HMOs often have zero monthly premiums, but copays per visit ($10 to $50 depending on the service), and an annual out-of-pocket maximum (usually $5,000 to $7,000). PPOs have higher monthly premiums (sometimes $50 to $200), lower in-network copays but higher out-of-network coinsurance, and higher out-of-pocket maximums. Neither HMO nor PPO covers dental, vision, or hearing unless the plan includes those as add-ons, which some do.

Frequently Asked Questions

Do I have to choose an HMO or PPO when I become may be able to access for Medicare through SSDI?

No. You are automatically enrolled in Original Medicare, which is neither an HMO nor a PPO. You can stay in Original Medicare for as long as you want. Choosing an HMO or PPO is optional and requires you to actively enroll in a Medicare Advantage plan during open enrollment or when you first become may be able to access.

Can I switch from an HMO to a PPO in the middle of the year?

Only during the annual open enrollment period (October 15 to December 7) or if you have a may have access to life event, such as moving out of your plan's service area. Otherwise, your plan choice is locked in until the next open enrollment period.

If I am on SSDI and Medicaid, which Medicare plan should I choose?

Contact your state Medicaid office first. Some states have preferred or required Medicare Advantage plans for people who are dually may be able to access. If your state does not mandate a plan, ask Medicaid which plans coordinate well with your state's Medicaid program, because Medicaid fills gaps that Medicare does not cover.

Does switching to a Medicare Advantage HMO or PPO change my SSDI payment?

No. Your SSDI cash payment, work incentives, and resource limits are not affected by which Medicare plan you choose. The change is only to your health insurance coverage and costs.

What happens to my coverage if I move and my Medicare Advantage plan does not serve my new area?

You can switch to a different plan or back to Original Medicare without waiting for open enrollment. Contact Medicare at 1-800-MEDICARE to report your move and request a plan change. The change usually takes effect the first of the month after you request it.

This guide is for general information only and is not medical, financial, legal, or other professional advice. For decisions specific to your situation, consult a qualified professional. See our Editorial Policy.