Types

• Health Maintenance Organizations (HMO)
• Preferred Provider Organization (PPO)
• Private Fee-for-Service (PFFS) Plans
• Special Needs Plans (SNPs)
• Health Maintenance Organization (HMO) Plan

Health Maintenance Organization (HMO) Plan

In most HMO Plans, you can only go to doctors, other health care providers, or hospitals on the plan’s list except in an emergency. You may also need to get a referral from your primary care doctor. Find and compare HMOs in your area.​

Can you get your health care from any doctor, other health care provider, or hospital?

In HMO Plans, you can’t get your health care from any doctor, other health care provider, or hospital. You generally must get your care and services from doctors, other health care providers, or hospitals in the plan’s network (except emergency care, out-of-area urgent care, or out-of-area dialysis). In some plans, you may be able to go out-of-network for certain services, usually for a higher cost. This is called an HMO with a point-of-service (POS) option.

Are prescription drugs covered?

In most cases, prescription drugs are covered in HMO Plans. Ask your agent. If you want Medicare prescription drug coverage, (Part D), you must join an HMO Plan that offers prescription drug coverage.

Do you need to choose a primary care doctor?

In most cases, yes, you need to choose a primary care doctor in HMO Plans.

Do you have to get a referral to see a specialist?

In most cases you have to get a referral to see a specialist in HMO Plans. Certain services, like yearly screening mammograms, don’t require a referral.

What else do you need to know about this type of plan?

• If your doctor or other health care provider leaves the plan, your plan will notify you. You can choose another doctor in the plan.

• If you get health care outside the plan’s network, you may have to pay the full cost.

• It’s important that you follow the plan’s rules, like getting prior approval for a certain service when needed.

Preferred Provider Organization (PPO) Plans

How PPO Plans Work

A Medicare PPO Plan is a type of Medicare Advantage Plan (Part C) offered by a private insurance company. In a PPO Plan, you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. You pay more if you use doctors, hospitals, and providers outside of the network.

Can you get your health care from any doctor, other health care provider, or hospital?

In most cases, you can get your health care from any doctor, other health care provider, or hospital in PPO Plans. PPO Plans have network doctors, other health care providers, and hospitals.

Each plan gives you flexibility to go to doctors, specialists, or hospitals that aren’t on the plan’s list, but it will usually cost more.

Are prescription drugs covered?

In most cases, prescription drugs are covered in PPO Plans. Ask the plan. If you want Medicare drug coverage, you must join a PPO Plan that offers prescription drug coverage. Remember, if you join a PPO Plan that doesn’t offer prescription drug coverage, you can’t join a Medicare Prescription Drug Plan (Part D).

Do you need to choose a primary care doctor?

You don’t need to choose a primary care doctor in PPO Plans.

Do you have to get a referral to see a specialist?

In most cases, you don’t have to get a referral to see a specialist in PPO Plans. If you use plan specialists, your costs for covered services will usually be lower than if you use non-plan specialists.

What else do you need to know about this type of plan?

• A PPO Plan isn’t the same as Original Medicare or a Medicare Supplement Insurance (Medigap) policy.

• PPO Plans usually offer extra benefits than Original Medicare, but you may have to pay extra for these benefits.

• PPOs tend to have higher copays, higher premiums for doctors and higher copays for prescriptions than HMOs because you have more freedom and do not need referrals.