Medicare Advantage plans can use different network structures. Three plan types you may encounter are HMO, PPO, and PFFS. The differences can affect which doctors you can use and what you pay.
HMO: Health Maintenance Organization
With an HMO, you generally need to receive nonemergency care from providers in the plan’s network, except in limited circumstances. Some HMO plans also use referrals for specialist care.
PPO: Preferred Provider Organization
A PPO generally provides more flexibility to use out-of-network providers, although your costs may be higher and not every service is necessarily available out of network.
PFFS: Private Fee-for-Service
PFFS plans can have different provider rules. Some may use networks, and providers must agree to the plan’s payment terms and conditions when required. Provider acceptance should be confirmed before receiving nonemergency care.
The letters are not enough
Before enrolling, verify your primary doctor, specialists, hospitals, pharmacies, and other facilities. Also review referral and prior-authorization requirements. For local guidance, see our articles on hospital networks in The Villages area and Medicare Advantage plans accepted by doctors in Summerfield.
Want help checking doctors and hospitals before enrolling? Request a Medicare review.
Network structure, provider participation, referrals, prior authorization, and out-of-network benefits vary by plan.