Medicare Advantage Plan Network Types
A plan network is the facilities, providers, and suppliers your health insurance carrier or plan has contracted with to provide health care services. The network types available with Medicare Advantage plans include:
Health Maintenance Organization (HMO)
HMOs are the most restrictive of the network types. HMOs require plan members only see doctors, other health care providers and hospitals in the plan’s network, except in an emergency, out-of-area urgent care or out-of-area dialysis. Members are required to select in-network primary care physicians (PCPs) who manage their care. Referrals are required to see other providers or specialists. Referrals aren't required for emergencies. Benefits aren't paid if care is received from out-of-network providers, except in an emergency.
Preferred Provider Organization (PPO)
PPO plan members have the flexibility to receive care from doctors, hospitals and providers in or out of the plan’s network. Members pay more if doctors, hospitals or providers outside of the network are used, except in emergencies. Referrals aren't required.
Private Fee-for-Service (PFFS)
Some PFFS plans have a network of doctors who have agreed to accept their plan. Other PFFS plans are non-network plans and don't offer this network security. Members may go to any Medicare-approved doctor, other health care provider or hospital that accepts the plan’s payment terms and agrees to treat a member. Members must inform their providers of the plan type before receiving services. The providers may accept the plans terms and conditions on a visit-by-visit basis. Providers must treat members in the case of an emergency. Payment is typically the same as Original Medicare, but may include excess charges if allowed in the payment terms and conditions.
Health Maintenance Organizations - Point of Service (HMO-POS)
Health Maintenance Organizations - Point of Service (HMO-POS) is an HMO with a more flexible network that allows plan members to seek care outside of the traditional HMO network under certain situations or for certain treatment. The plan may allow members to access some services out-of-network, or without a referral or prior approval for a higher cost. Members must choose PCPs from the POS network.
