Comparing Medicare Advantage Plan Types

Adapted from Understanding Medicare Advantage Plans, Centers for Medicare & Medicaid Services. The selected guidance concerns Medicare coverage and payment, not a recommendation for medical treatment. Numbered page references below refer to the linked source publication.

Coverage can depend on medical necessity, the setting, provider participation, and your plan’s rules. Use the cited publication for the full conditions and check the plan year when comparing costs or enrollment choices.

Types of Medicare Advantage Plans

There are different types of Medicare Advantage Plans:

• Health Maintenance Organization (HMO) Plan: Go to page 15.
• HMO Point-of-Service (HMOPOS) Plan: Go to page 15.
• Preferred Provider Organization (PPO) Plan: Go to page 15.
• Private Fee-for-Service (PFFS) Plan: Go to page 16.
• Special Needs Plan (SNPs): Go to page 17.
• Medical Savings Account (MSA) Plan: Go to page 19.

The area where you live might have all, some, or none of these plan types available, and multiple plans of the same type might be available in your area. To find available Medicare Advantage Plans, visit Medicare.gov/plan-compare, read your “Medicare & You” handbook, or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

Health Maintenance Organization (HMO) Plan

A type of Medicare Advantage Plan that generally gives health care coverage exclusively from doctors, other health care providers, or hospitals in the plan’s network (except emergency care, out-of-area urgent care, or temporary out-of-area dialysis). A network is a group of doctors, hospitals, and medical facilities that contract with a plan to give services. Many HMOs also require you to get a referral from your primary care doctor for specialist care, so that your care is coordinated.

Can I get my health care from any doctor, other health care provider, or hospital? No. You generally must get your care and services from doctors, other health care providers, or hospitals in the plan’s network (except for emergency care, out-of-area urgent care, or temporary out-of-area dialysis, which is covered whether it’s given in the plan’s network or outside the plan’s network). Some HMO plans (known as HMO Point-of-Service (HMOPOS) plans) offer an out-of-network benefit for some or all covered benefits, but you’ll usually pay a higher copayment or coinsurance.

If you get non-emergency health care outside the plan’s network without authorization, you may have to pay the full cost. It’s important that you follow the plan’s rules, like getting prior approval (prior authorization) for a certain service when needed. In most cases, you need to choose a primary care doctor. Certain services, like yearly screening mammograms, don’t require a referral. If your doctor or other health care provider leaves the plan’s network, your plan must notify you. You will need to choose another doctor in the plan’s network.

Do these plans cover prescription drugs? In most cases, yes. If you’re planning to join an HMO and want Medicare drug coverage (Part D), you must join an HMO Plan that offers Medicare drug coverage. If you join an HMO Plan without drug coverage, you can’t join a separate Medicare drug plan.

Preferred Provider Organization (PPO) Plan

A type of Medicare Advantage Plan that has a network of doctors, specialists, hospitals, and other health care providers you can use. You pay less if you go to providers and facilities that are in the plan’s network. You can generally go to out-of-network providers for covered services, but you’ll usually pay more.

Can I get my health care from any doctor, other health care provider, or hospital? Yes. You can also use out-of-network providers for covered services, usually for a higher cost, if the provider agrees to treat you and hasn’t opted out of Medicare (for Medicare Part A and Part B items and services). You’re always covered for emergency and urgent care.

Before you get services from an out-of-network provider, you may want to ask for an organization determination from your plan to make sure that the services are medically necessary and your plan covers them. Go to page 9 for more information on organization determinations.

Do these plans cover prescription drugs? In most cases, yes. If you’re planning to join a PPO Plan and you want Medicare drug coverage (Part D), you must join a PPO Plan that offers Medicare drug coverage. If you join a PPO Plan without drug coverage, you can’t join a separate Medicare drug plan.

Private Fee-for-Service (PFFS) Plan

A type of Medicare Advantage Plan offered by a private health insurance company that determines how much it will pay doctors, other health care providers, and hospitals, and how much you must pay when you get care.

Can I get my health care from any doctor, other health care provider, or hospital? You can go to any Medicare-approved doctor, other health care provider, or hospital that accepts the plan’s payment terms, agrees to treat you, and hasn’t opted out of Medicare (for Medicare Part A and Part B items and services).

If you join a PFFS Plan that has a network, you can also use any of the network providers who have agreed to treat plan members. You don’t need to get prior approval (prior authorization) for Medicare Part A and B items and services. You can also choose an out-of-network doctor, hospital, or other provider who accepts the plan’s terms, but you may pay more. Typically, your insurance plan ID card tells your provider that you belong to a PFFS Plan.

If your provider doesn’t agree to the plan’s terms and conditions of payment, the plan is only required to pay them for emergency services, urgently needed services, and out-of-area dialysis. For other covered services, you’ll need to find another provider that will accept your PFFS Plan.

Note: A PFFS Plan may also allow “balance billing,” which means that a provider can charge up to 15% more than the amount Medicare pays, and bill you for that amount.

If your plan allows balance billing, you may have to pay both the plan’s copayment or coinsurance and the difference between what the provider charged and the amount Medicare pays.

Do these plans cover prescription drugs? Sometimes. If your PFFS Plan doesn’t offer Medicare drug coverage, you can join a separate Medicare drug plan to get Medicare drug coverage (Part D).

Special Needs Plan (SNP)

Special Needs Plans give benefits and services to people with specific severe or chronic diseases, certain health care needs, or who have Medicaid coverage. You may qualify for an SNP if you have Medicare Parts A and Part B, live in the plan’s service area, and meet the eligibility requirements for one of the following 3 types of SNPs (or a subset of one of these groups):

• Chronic condition SNP (or C-SNP): You have one or more specific severe or disabling chronic conditions like:
• Cancer
• Certain autoimmune disorders
• Certain cardiovascular disorders
• Certain chronic and disabling mental health conditions
• Certain chronic gastrointestinal diseases
• Certain chronic lung disorders
• Certain neurological disorders
• Certain severe hematological disorders
• Chronic alcohol use disorder and other substance use disorders
• Chronic heart failure
• Chronic kidney disease and End-Stage Renal Disease (ESRD)
• Dementia
• Diabetes mellitus
• HIV/AIDS
• Stroke
• Institutional SNP (or I-SNP): You live in the community but need the level of care a facility offers, or if you live (or are expected to live) for at least 90 days straight in a facility like a:
• Intermediate care facility
• Long-term care hospital
• Nursing facility
• Psychiatric hospital
• Rehabilitation hospital
• Skilled nursing facility
• Swing bed hospital
• Other facility that offers similar long-term health care services, and whose residents have similar needs and health care status as residents of the facilities listed above
• Dual Eligible SNP (or D-SNP): You’re eligible for both Medicare and Medicaid. D-SNPs contract with your state Medicaid program to help coordinate your Medicare and Medicaid benefits. Some D-SNPs, called “integrated D-SNPs,” combine both your Medicare benefits and most or all of your Medicaid benefits and services through a single plan. There are different types of integrated D-SNPs, but all of them must:
• Give you one member ID card that works for both your Medicare and Medicaid coverage.
• Offer a single health risk assessment that covers both programs.
• Provide you with a care coordinator or case manager to help manage your health care and develop a personal care plan (a customized plan that covers your medical and social needs, health goals, and coordination of your care).
• Have one appeals and grievance process that lets you file a complaint or appeal with your plan for any issue related to your Medicare or Medicaid coverage.

Plan availability varies by:

• Geographic location (state and county).
• Which SNP types or chronic conditions the plan covers.
• Enrollment periods and other requirements.

You can only stay enrolled in an SNP if you continue to meet the special eligibility rules for the SNP.

SNPs are either PPO, HMO, or HMOPOS plan types, and cover the same Medicare Part A and Part B services that all Medicare Advantage Plans cover. SNPs also include care coordination services and tailor their benefits, provider choices, and list of drugs they cover (formularies) to best meet the specific needs of the groups they serve. However, SNPs might also cover extra services tailored to the special groups they serve. For example, if you have a severe or chronic condition, like cancer or chronic heart failure, and you require a hospital stay, a SNP may cover extra days in the hospital.

Can I get my health care from any doctor, other health care provider, or hospital? If your SNP is also an HMO, you generally must get your care and services from doctors, other health care providers, or hospitals in the plan’s network (except for emergency care, out-of-area urgent care, or out-of-area dialysis). You may be required to have a primary care doctor.

However, if your SNP is also a PPO, then you may get services from any qualified provider or hospital, but usually at a higher cost than you would pay for services from a network provider.

SNPs typically have specialists in the diseases or conditions that affect their members. Both HMO and PPO SNPs may require you to have a care coordinator to help with your health care. A care coordinator is someone who helps make sure people get the right care and information. For example, a care coordinator with a SNP for people with diabetes might help members monitor their blood sugar and follow their diet.

Do these plans cover prescription drugs? Yes. All SNPs must include Medicare drug coverage (Part D).

Medicare Medical Savings Account (MSA) Plan

Medicare Medical Savings Account (MSA) Plans combine a high-deductible insurance plan with a medical savings account:

1. High-deductible health plan: The first part of an MSA Plan is a special type of high-deductible Medicare Advantage Plan. The plan will only begin to cover your costs once you meet a high yearly deductible, which varies by plan.

2. Medical savings account: The second part of an MSA is a special type of savings account. The MSA Plan deposits money into your account that you can use to pay for your health care costs.

Who can’t join an MSA Plan? You can’t join an MSA Plan if:

• You have health coverage that would cover all or part of the plan’s deductible.
• You joined another Medicare Advantage Plan. You’ll need to disenroll from your current plan before you can join an MSA Plan.
• You get benefits from the U.S. Department of Defense (TRICARE) or the U.S. Department of Veterans Affairs (VA).
• You’re a retired federal government employee who is enrolled in a plan through the Federal Employees Health Benefits Program (FEHBP).
• You’re eligible for Medicaid.
• You’re currently getting hospice care.
• You live outside the U.S. more than 183 (total) days a year.

If you’re interested in joining a particular MSA Plan, you’ll need to contact the plan to join. The plan will tell you how to set up your medical savings account with a bank that the plan selects. You must set up this account before you can join the plan. After you join, you’ll get a letter from the plan telling you when your coverage begins. Once you join and have MSA coverage:

• Medicare gives the plan an amount of money each year for your health care.
• The plan deposits money into your account each year on your behalf. You can’t deposit your own money.
• You can use the money in your account to pay for health care costs, including health care costs that aren’t covered by Medicare.
• If you use all the money in your account and you have more health care costs, you’ll have to pay for your Medicare-covered services out-of-pocket until you reach your plan’s deductible.
• During the time you’re paying out-of-pocket for services before the deductible is met, doctors and other providers can’t charge you more than the Medicare-approved amount.
• Your payments for Medicare-covered Part A and Part B services count toward your plan’s deductible. After you reach your deductible, your plan will cover your Medicare-covered services.
• Money left in your account at the end of the year stays in the account and may be used for health care costs in future years. If you stay with the same MSA Plan the following year, the new deposit will be added to any leftover amount.

MSA plans and your taxes If you use funds from your account, when you file your income taxes you must include IRS Form 8853 with information on how you used the money in your medical savings account.

Each year, you should get a 1099-SA form from your bank that includes all of the withdrawals from your account. You’ll need to show that you’ve had Qualified Medical Expenses equal to at least this amount, or you may have to pay taxes and other penalties.

Visit IRS.gov/forms-pubs/about-publication-969 to get more tax information related to MSA plans, like a list of Qualified Medical Expenses.

If you have one, talk to your personal financial advisor about how choosing an MSA Plan could affect your financial situation.

Can I get my health care from any doctor, other health care provider, or hospital? Yes. You can go to any Medicare-approved doctor, other health care provider, or hospital that agrees to treat you and hasn’t opted out of Medicare (for Medicare Part A and Part B items and services). MSA Plans usually don’t have a network of doctors, other health care providers, or hospitals.

Do these plans cover prescription drugs? No. If you join a Medicare MSA Plan and want Medicare drug coverage (Part D), you’ll have to join a separate Medicare drug plan.

Source and further reading

Understanding Medicare Advantage Plans — Centers for Medicare & Medicaid Services. Public domain U.S. government educational material, accessed October 28, 2026. Fynoptic has selected sections, removed print navigation, and reformatted the text for this guide. The agency does not endorse Fynoptic.