Medicare Advantage HMO vs. PPO in Utah (2026 Guide)

All 29 Utah counties, sorted by Medicare Advantage enrollment. Plan columns count general-population plans (Special Needs Plans excluded) sold in the county for 2026; a plan is counted once per county. “$0-premium” = plans of any type with no monthly plan premium (you still pay Part B). Enrollment columns count all Medicare Advantage enrollees, including Special Needs Plans, so a county can show PPO enrollees with no general-population PPO for sale; counties with 10 or fewer enrollees in a type are suppressed by CMS. Sources: CMS CY2026 Landscape file — cms.gov; CMS Monthly MA Enrollment by State/County/Plan Type, August 2026 — cms.gov. Public CMS data, not a recommendation; we do not offer every plan available in your area.

Three things in the table are easy to miss. In 14 counties, including Tooele, Box Elder, Wasatch and every county in the Uinta Basin and the southeast, there is no plain HMO at all: the only non-PPO choice is an HMO-POS. In Rich County there is no HMO of any kind, only PPOs. And Wayne County has exactly one general-population plan, Select Health's HMO, while Daggett County has none; retirees there choose between Original Medicare (with or without Medigap) and a Special Needs Plan if they qualify. The 2027 lineup can differ: plans enter and leave counties every year, and our guide to plan non-renewals explains the rights that opens.

How do out-of-pocket limits differ between HMO and PPO plans?

Every Medicare Advantage plan must cap what you pay in a year for covered Part A and Part B services, which is the feature Original Medicare lacks. CMS sets the ceilings each year from Medicare's own cost distribution, and for 2026 there are three tiers. A plan using the “mandatory” (highest) limit may set its in-network maximum as high as $9,250; the “intermediate” tier tops out at $6,750 and the “lower” tier at $4,200. Plans that choose a lower tier are allowed to charge higher cost-sharing for some services, which is the trade CMS built into the rule.

The PPO wrinkle is the second number. Because a PPO pays for out-of-network care, it carries a combined maximum that counts in- and out-of-network spending together, and CMS sets that at 1.5 times the in-network figure: $13,900 for a mandatory-tier plan, $10,100 for intermediate and $6,300 for lower. An HMO has no out-of-network benefit, so it has no combined limit and its in-network figure is the whole story. An HMO-POS with an out-of-network benefit has both.

General-population Medicare Advantage plans priced in at least one Utah county for 2026. “In-network maximum” is the plan's filed in-network maximum out-of-pocket; PPO combined maximums are not in the landscape file and appear in each plan's Evidence of Coverage. Premium = monthly Part C + Part D consolidated premium (Part C premium for plans without drug coverage). Source: CMS CY2026 Landscape file, Utah rows, via the Ambrose Insurance Brain — cms.gov. CMS CY2026 MOOP limits — cms.gov. Not a recommendation; we do not offer every plan available in your area.

In Utah's 2026 filings the spread inside each type is wider than the gap between them. The 26 PPOs run from a $4,500 in-network maximum (a Regence plan without drug coverage) to the full $9,250 (a Devoted Health plan that pays part of your Part B premium), with a median of $5,900. The HMOs sit in a narrower band, $5,000 to $6,700, median $5,600, and the HMO-POS plans from $3,500 to $6,700. The pattern worth knowing: all four Utah PPOs with in-network limits of $8,900 or more are Part B give-back plans (though not every give-back plan has a high limit), because a give-back is funded in part by shifting cost to the members who get sick. Read the maximum before the premium, and for a PPO read both maximums.

Which type fits you? A seven-question test

1. Are all of your doctors in one system? If your primary care doctor, specialists and hospital are all Intermountain, or all University of Utah Health, or all within another single system, an HMO built around that system usually has lower copays and simpler rules. Check each doctor by name on the plan's directory, not the system's, and confirm the hospital.
2. Do you see doctors in more than one system, or out of state? A retiree in St. George who sees a cardiologist in Las Vegas, or a Moab retiree whose oncologist is in Grand Junction, needs either a PPO whose out-of-network benefit reaches those providers or an HMO whose network includes them. An HMO-POS covers such visits only if they fall under its listed point-of-service benefits.
3. Do you spend months away from home? Snowbirds in Arizona, Nevada or Mexico face two questions: whether routine care away is covered (PPO out-of-network yes, HMO emergencies and urgent care only) and whether you still live in the plan's service area, since a plan can disenroll you if you move outside it. Our snowbird guide compares this with Original Medicare plus Medigap, which works in all 50 states.
4. Do you want to self-refer to specialists? PPOs and most PPO-type plans do not require referrals; most HMOs and HMO-POS plans do. If you manage several conditions and change specialists often, the referral step is a real cost in time.
5. What is the worst year you could afford? Compare the in-network maximum on every plan you consider, and for a PPO add the combined maximum from its Evidence of Coverage. A $0-premium plan with a $9,250 limit and a $39 plan with a $5,500 limit are different bets on your health; neither is free, because both sit on top of the $202.90 monthly Part B premium for 2026.
6. Are your drugs covered? Neither type lets you add a stand-alone Part D plan, so the plan's formulary is your only drug coverage. Enter every prescription on Plan Finder; the $2,100 Part D cap applies inside both types.
7. Is this your first Medicare Advantage plan? If you are leaving Original Medicare or a Medigap policy for the first time, federal law gives you a 12-month trial right: return to Original Medicare within a year and you can buy a Medigap policy (or get your old one back if the company still sells it) with no health questions. That safety net is the same whether you try an HMO or a PPO.

When can you switch between an HMO and a PPO?

Only in a window. Open Enrollment, October 15 to December 7, lets anyone with Medicare change plans, with the new plan starting January 1; the 2027 plans and their networks are published on Plan Finder before it opens, and your current plan's Annual Notice of Change arrives by September 30. If you are already in a Medicare Advantage plan, the Medicare Advantage Open Enrollment Period, January 1 to March 31, allows one more switch, to another Medicare Advantage plan of any type or back to Original Medicare with a stand-alone drug plan. Outside those dates you need a Special Enrollment Period: moving out of your plan's service area, your plan leaving Medicare or your county, qualifying for Extra Help or Medicaid, or the 12-month trial right described above. Utah's Medigap birthday rule is a separate right for people who already hold Medigap; it does not move you between Advantage plans.

One caution when you switch types mid-treatment. Whether the new plan is an HMO or a PPO, federal rules give you at least 90 days before it can require a new prior authorization for care already under way, and your current doctors remain covered for that transition even if they are out of the new network. After that, the new plan's network rules govern, so line up in-network doctors before the switch takes effect rather than after.

Frequently asked questions

Sources

• Medicare.gov — Health Maintenance Organizations (HMOs): network rule, emergency / out-of-area urgent care / dialysis exceptions, primary care doctor and referrals, HMO-POS out-of-network option, full-cost warning, prior authorization protections: medicare.gov — HMOs
• Medicare.gov — Preferred Provider Organizations (PPOs): in-network vs. out-of-network cost, no primary care doctor or referrals, out-of-network providers must participate in Medicare or accept assignment, contact the plan before out-of-network services: medicare.gov — PPOs
• Medicare.gov — Compare types of Medicare Advantage Plans (HMO, PPO, PFFS, SNP, MSA side-by-side table): medicare.gov — compare plan types
• Medicare.gov — Your health plan options (plan types; a plan can disenroll you if you move outside its service area): medicare.gov — health plan options
• CMS — “Understanding Medicare Advantage Plans,” product 12026 (Section 3: HMO, HMOPOS, PPO, PFFS, SNP, MSA definitions; p. 5: 12-month Medigap trial right; yearly in-network and out-of-network limits): medicare.gov — publication 12026 (PDF)
• CMS — CY 2026 MOOP and Cost Sharing Limit Calculations (“MOOP Limits” Tables 1–3: in-network lower $4,200, intermediate $6,750, mandatory $9,250; combined $6,300 / $10,100 / $13,900), from the Medicare Advantage Rates & Statistics page: cms.gov — MA rates & statistics
• CMS — CY2026 Medicare Advantage and Part D Landscape file, Utah rows (every plan by county with plan type, SNP indicator, premiums and in-network MOOP), accessed via the Ambrose Insurance Brain: cms.gov — landscape files
• CMS — Monthly MA Enrollment by State/County/Plan Type, August 2026 (Utah rows: HMO/HMOPOS 164,497, Local PPO 105,902, MSA 139, Cost 684, total 271,278): cms.gov — enrollment by plan type
• Medicare.gov — Understanding Medicare Advantage & Medicare Drug Plan Enrollment Periods, product 11219 (Open Enrollment October 15 to December 7; Medicare Advantage Open Enrollment January 1 to March 31; Special Enrollment Periods): medicare.gov — publication 11219 (PDF)
• Medicare.gov — Medicare costs (2026 Part B premium $202.90): medicare.gov — costs
• Utah Insurance Department — Medicare / Medigap / Medicare Advantage consumer page (Utah SHIP (877) 424-4640 or (801) 538-3910): insurance.utah.gov

About this article. Written by the Utah Retirement Income Data Desk and reviewed by Brian Penner, Retirement income & long-term care planner. Educational only — not medical, financial, or legal advice. Plan-type rules are quoted from Medicare.gov and CMS product 12026 as of September 14, 2026; the 2026 out-of-pocket limits are from CMS's CY2026 MOOP calculations; the Utah plan counts, premiums and maximums are our own tabulation of the CMS CY2026 landscape file, and the enrollment figures are from CMS's August 2026 enrollment-by-plan-type file. Plan availability, networks, premiums and maximums change for 2027 when CMS publishes the new landscape in the fall; plan and carrier names are public CMS data shown for comparison and are not endorsements or recommendations. Confirm current plans on Medicare.gov or call 1-800-MEDICARE before you act. Utah Retirement Income is a licensed independent insurance agency (NPN 16493717) and is not a government agency; we are not connected with or endorsed by Medicare, the Centers for Medicare & Medicaid Services, the Social Security Administration, or any government program, and nothing here should be read as an endorsement by them. 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 — in Utah, the Utah SHIP at (877) 424-4640 — to get information on all of your options. A $0-premium plan is not free; you still pay Part B premiums and cost-sharing. If you call or text us, you consent to be contacted at the number you provide about your options; message and data rates may apply, and you can opt out at any time by replying STOP.