Medicare Advantage Plan Types
Compare the structures used by HMO, HMO-POS, PPO, PFFS, and special-needs plans.
HMO and HMO-POS
An HMO generally requires routine care in its network, with exceptions for emergencies, out-of-area urgent care and temporary out-of-area dialysis. Most HMOs require a primary physician and specialist referral. An HMO-POS can offer specific nonemergency out-of-network benefits, usually at higher cost; ask exactly which services qualify and whether approval is necessary.
Official source: Medicare: HMO plans ↗ · Medicare: Compare plan types ↗
PPO
A PPO has an in-network cost advantage and generally permits covered out-of-network care at a higher member cost. It ordinarily does not require selection of a primary doctor or a specialist referral, but other plan rules can still apply. Ask the out-of-network provider whether it will treat you under the exact plan and request a coverage determination before expensive nonemergency care.
Official source: Medicare: PPO plans ↗ · Medicare: Medicare Advantage guide ↗
Private Fee-for-Service
A PFFS plan sets payment terms for providers and members. A provider may decide whether to accept those terms for a visit unless it has a network contract to treat plan members. A PFFS plan may or may not include drug coverage; if it does not, Medicare says a separate Part D plan may be needed. Carry the PFFS card and confirm acceptance before nonemergency care.
Official source: Medicare: PFFS plans ↗
Special Needs Plans
SNPs serve people with qualifying chronic conditions, institutional needs or both Medicare and Medicaid eligibility. Medicare says SNPs use HMO or PPO structures, include care coordination, and must include Part D. The plan verifies membership criteria and service area; you generally can remain enrolled only while you satisfy its special conditions. Confirm that the plan’s providers and drugs fit the condition.
Official source: Medicare: Special Needs Plans ↗
Compare the contract rather than the acronym
Obtain the exact year’s Evidence of Coverage, provider directory, drug list, premium and annual medical maximum. Find out what out-of-network care counts toward the limit and whether referrals or approval are required. Two plans with the same type may have different local networks and benefits. Medicare’s comparison tool shows options for the specific ZIP code.
Official source: Medicare: Compare plan types ↗ · Medicare: Evidence of Coverage ↗ · Medicare: Compare plans ↗