HMO, PPO, PFFS, MSA, and SNP
Medicare Advantage plan types compared
Two plans can have the same premium, the same carrier, and the same county, and still behave completely differently when you need care. The letters after the plan name are the reason. Here is what each one actually changes.
On this page
The two questions that separate every plan type
Strip away the marketing and every Medicare Advantage plan type is answering two questions. First: what happens when you see a provider who is not in the plan’s network? Second: do you need a referral or a prior authorization before the plan will pay?
Everything else, including premiums and extra benefits, sits on top of those two answers. If you get them right, the plan works quietly in the background. If you get them wrong, you find out at the worst possible moment.
All Medicare Advantage plan types compared
Availability varies by county. Not every type is offered everywhere, and HMO and PPO plans make up the large majority of what most people will see.
Swipe the table sideways to see every column.
| Plan type | Out-of-network care | Referrals | Drug coverage | Often suits |
|---|---|---|---|---|
| HMO | Generally not covered except emergency, urgent care, and out-of-area dialysis | Usually required to see a specialist | Almost always included | People settled with one health system, who want the lowest cost sharing and do not travel for care |
| HMO-POS | Covered for some services at higher cost sharing, defined by the plan | Usually required | Almost always included | People who want HMO pricing with a defined escape hatch for specific services |
| PPO (local or regional) | Covered, at higher cost sharing, from any provider who accepts Medicare and agrees to treat you | Usually not required | Almost always included | People who want flexibility, split time between two places, or want specialists without referrals |
| PFFS | Any provider may treat you if they accept the plan’s terms of payment, and they may decide visit by visit | Not required | Sometimes. If not included, you may add a separate Part D plan | Rare now. People in areas with few network plans |
| MSA | Any Medicare-approved provider | Not required | Not included. You must add a separate Part D plan | Rare. People comfortable with a high deductible and managing a savings account |
| SNP (D-SNP, C-SNP, I-SNP) | Usually structured like an HMO | Usually required | Always included | Only people who meet the specific eligibility condition |
One rule catches people across every type: if your Medicare Advantage plan already includes drug coverage and you enroll in a separate stand-alone Part D plan, Medicare will disenroll you from your Medicare Advantage plan and return you to Original Medicare. The exceptions are PFFS plans without drug coverage, and MSA plans.
HMO and HMO-POS
An HMO builds its cost advantage by directing care through a defined network and a primary care physician who coordinates it. In exchange you generally get lower copays and richer supplemental benefits than a comparable PPO in the same county.
The trade is real. Outside emergencies, urgent care, and out-of-area dialysis, care from a provider outside the network is generally your bill in full. Not at a higher rate. In full.
The out-of-state grandchild problem
A retiree in Las Vegas has an HMO with excellent local coverage. She spends two months each year with family in Chicago. A routine follow-up appointment there is not an emergency and not urgent care, so the HMO does not cover it. Her options are to pay privately, delay the visit, or use urgent care for something that is not urgent.
A PPO in the same county would have covered that visit at out-of-network cost sharing. It might have cost her more in monthly copays all year, and been worth it.
HMO-POS adds a point-of-service option: the plan defines specific services it will cover out of network, at higher cost sharing. Read exactly which services, because it is usually a short list and rarely covers everything.
PPO
A PPO covers out-of-network care at a higher cost-sharing level, and usually does not require referrals. That flexibility is the product.
Three things to check before assuming a PPO solves the network problem.
Regional PPOs cover a whole state or a multi-state region rather than a set of counties, which can matter if you split your year between two homes. Ask us to check what is offered at both addresses.
PFFS and MSA
These two are uncommon, and most people will never be offered one. They are included here because they behave so differently that mistaking one for a standard plan causes real problems.
A Private Fee-for-Service plan sets its own payment terms rather than contracting a network. Any provider who accepts Medicare may treat you if they agree to those terms, and they can make that decision at each visit. There is no guarantee the same clinic accepts the plan in March that accepted it in January. Some PFFS plans include drug coverage and some do not; when they do not, you may add a stand-alone Part D plan without losing the plan.
A Medical Savings Account plan pairs a high deductible with a bank account the plan deposits money into each year. You spend from the account, then pay out of pocket until the deductible is met, after which the plan covers Medicare-covered services. MSA plans never include drug coverage, so a separate Part D plan is necessary. They also do not cover hospice, which stays with Original Medicare, and they are not available to people with Medicaid or certain other coverage.
If an advertisement offers a plan that sounds unlike anything described on this page, check the plan type before anything else. It is printed on the Summary of Benefits, and it explains more about how the plan will behave than the premium does.
Eligibility-restricted plans
Special Needs Plans
A Special Needs Plan is a Medicare Advantage plan restricted to people who meet a specific condition. Because everyone enrolled shares that condition, the benefits, the provider network, and the drug formulary can be built around it. All SNPs include Part D drug coverage.
Swipe the table sideways to see every column.
| Type | Who qualifies | What it typically adds | When you can join |
|---|---|---|---|
| D-SNP, dual eligible | People with both Medicare and Medicaid | Coordination between the two programs, often very low or no cost sharing, care coordinators, and benefits aimed at everyday needs | Depends on your Medicaid status. There is a monthly opportunity to join certain integrated plans |
| C-SNP, chronic condition | People with a qualifying chronic condition such as diabetes, chronic heart failure, or end-stage renal disease | A network and drug formulary built around the condition, plus condition-specific care management | A Special Enrollment Period based on the diagnosis, with confirmation from your provider |
| I-SNP, institutional | People living in a nursing home or similar facility for 90 days or more, or needing that level of care at home | Clinicians who visit the facility, and coordination with facility staff | An ongoing Special Enrollment Period while the situation applies |
If you have both Medicare and Medicaid, a D-SNP is usually worth serious consideration and is often overlooked. We cover it in more detail on the dual eligibility page. Veterans using VA health care have their own considerations, covered on the veterans page.
Prior authorization and appeals
This is the practical difference between Medicare Advantage and Original Medicare that people feel most. Original Medicare requires prior authorization for very few services. Medicare Advantage plans use it routinely, and the rules changed recently in ways that work in your favor.
Swipe the table sideways to see every column.
| Request type | Deadline for the plan to decide | What triggers it |
|---|---|---|
| Expedited, or urgent | 72 hours | Your provider indicates that waiting for a standard decision could seriously jeopardize your life, health, or ability to regain maximum function |
| Standard, or non-urgent | 7 calendar days | Everything else |
| Denial notice | Must include a specific reason | Applies to every denial, so you know what to appeal and on what grounds |
| Electronic prior authorization | Interfaces go live January 1, 2027 | Plans must offer an application interface so your provider’s system can submit and track requests electronically |
Requirements from the CMS Interoperability and Prior Authorization final rule, CMS-0057-F, which applies to Medicare Advantage, Medicaid, CHIP, and Marketplace plans.
If a service is denied
You have a formal appeal path, and it works. Ask your plan for a written denial with the reason, ask your provider for a letter of medical necessity, and file. The first level is a reconsideration by the plan itself. If that fails, the case goes automatically to an independent review entity that does not work for the plan. Beyond that there are further levels, including an administrative law judge.
Expedited appeals follow the 72-hour timeline. If care has already been denied and delay is dangerous, say so explicitly and ask for the expedited process by name.
How to choose between them
Work through these in order. The first answer that rules a plan out saves you from analyzing everything else about it.
Questions people ask us about plan types
What is the main difference between a Medicare Advantage HMO and PPO?
Out-of-network care. An HMO generally covers nothing outside its network except emergencies, urgent care, and out-of-area dialysis. A PPO covers out-of-network care at higher cost sharing. HMOs usually require referrals to specialists; PPOs usually do not. HMOs are typically cheaper when you stay in network.
Can I see any doctor with a Medicare Advantage PPO?
You can see any provider who accepts Medicare and agrees to treat you, and the plan will pay its out-of-network share. The provider is not required to accept you, so call ahead rather than assuming.
Do all Medicare Advantage plans require prior authorization?
Most use it for at least some services, commonly imaging, surgery, skilled nursing, home health, and specialty drugs. The lists differ by plan. Since January 1, 2026 plans must decide urgent requests within 72 hours and standard requests within 7 calendar days, and must give a specific reason for any denial.
Can I add a separate drug plan to my Medicare Advantage plan?
Usually no. If your plan already includes drug coverage and you enroll in a stand-alone Part D plan, Medicare disenrolls you from the Medicare Advantage plan. The exceptions are PFFS plans without drug coverage and MSA plans.
What is a D-SNP and should I look at one?
A dual eligible Special Needs Plan is for people who have both Medicare and Medicaid. It coordinates the two programs, and cost sharing is often very low. If you have both, it is usually worth comparing against a general Medicare Advantage plan.
What are Star Ratings and do they matter?
Medicare rates plans from one to five stars on quality, member experience, and customer service, updated every autumn. They are a useful signal alongside network and drug coverage, not a substitute for checking those. CMS is revising which measures count starting with the 2027 measurement period.
Are HMO plans always cheaper?
Usually lower in monthly cost and in-network copays, in the same county. Whether they are cheaper for you depends on whether you ever need care outside the network, because that care is generally not covered at all.
Which plan type is best?
There is no best type, only a best fit. The answer depends on where your doctors are, whether you travel, which drugs you take, and whether you qualify for a Special Needs Plan. That is what a plan review is for.
Official resource
Read the federal definitions, then compare what is actually sold near you
Medicare.gov defines every plan type and its rules. A licensed agent can tell you which types are offered in your county and check your providers against each. Agents do not provide medical, legal, or official eligibility advice.
Sources used on this page
Personal guidance · No additional fee