Medicare 2026

HMO, PPO and Other Medicare Advantage Plan Types: How the Networks Work

If you're sorting through Medicare Advantage choices, one of the first things to understand is how each plan type handles its network — the doctors, hospitals and other providers you can use. Networks shape your cost, your access and sometimes whether you need a referral before you see a specialist. Here's a plain-English tour of the main plan types and the rules that come with them.

Medicare Advantage, in one paragraph

Medicare Advantage (Part C) is private insurance that replaces how you receive your Part A and Part B benefits. Plans must cover everything Original Medicare covers, with one exception worth knowing: hospice continues to be covered by Original Medicare even if you're enrolled in a Medicare Advantage plan. Most Medicare Advantage plans also include Part D prescription drug coverage and may offer extras not found in Original Medicare. The catch — and the point of this article — is that each plan builds its own network and sets its own rules for using it.

HMO: stay in network, often with a referral

A Health Maintenance Organization (HMO) is the most network-restricted plan type. In general, an HMO covers care only when you use a provider in the plan's network. The main exceptions are emergency care, urgent care and out-of-area dialysis, which are covered no matter where you receive them.

HMOs commonly ask you to pick a primary care provider and get a referral before seeing a specialist. If you go outside the network for non-emergency care without authorization, the plan usually won't pay, and you could owe the full bill.

This structure can keep coordination simple — your primary care provider helps steer the care — but it does mean checking the plan's provider directory carefully before you enroll, and again when you need a new specialist.

PPO: more flexibility, usually at a higher price

A Preferred Provider Organization (PPO) also has a network, but it covers out-of-network care too, usually at a higher cost to you. You generally don't need a referral to see a specialist.

The trade-off is cost-sharing. In-network visits typically carry lower copays or coinsurance; the same service out of network will usually cost more. Some services may still require prior authorization regardless of whether the provider is in or out of network, so read the plan documents.

Other Medicare Advantage plan types

Beyond HMOs and PPOs, you may see:

• Private Fee-for-Service (PFFS) plans. These set their own payment terms with providers. A provider can decide, visit by visit, whether to accept the plan's terms, so confirming acceptance before each appointment matters.
• Medical Savings Account (MSA) plans. These pair a high-deductible health plan with a bank account the plan funds; you use the account for qualified medical costs. MSAs don't include Part D, so you'd pair one with a stand-alone drug plan.
• Special Needs Plans (SNPs). These are tailored to people with specific situations — a chronic condition, institutional care needs, or both Medicare and Medicaid. SNPs include Part D and typically coordinate care around the condition they serve.

Every one of these plan types must cover the same services Original Medicare does; what varies is how they build the network, what they charge and how they manage care.

Networks, referrals, prior authorization: read before you enroll

Two documents answer most of the practical questions:

• The provider directory lists in-network doctors, hospitals, labs and pharmacies. Directories change during the year, so verify your providers.
• The Evidence of Coverage spells out referral rules, prior-authorization requirements and what you pay for each service.

If keeping a current doctor matters, confirm that provider is in network for the specific plan you're considering — not just "the carrier."

How Medicare Advantage compares with Original Medicare + Medigap

A quick, neutral comparison: Original Medicare lets you use any provider in the U.S. who accepts Medicare, with no network and no referrals, and a Medigap policy can help cover the out-of-pocket costs Original Medicare leaves behind. Medigap doesn't include drug coverage, so you'd add a stand-alone Part D plan. Medicare Advantage uses networks and plan rules, often bundles drug coverage, and sets a yearly limit on in-network medical out-of-pocket costs. There's no universally "right" choice — it depends on your providers, your budget, how you like to get care, and what's offered where you live.

Part D costs you can count on nationally

For prescription drug coverage in 2027, the Part D out-of-pocket cap is $2,400 (up from $2,100 in 2026), the maximum deductible any Part D plan may charge is $700, and the base beneficiary premium used in the late-enrollment penalty calculation is $41.33. Plan premiums themselves are set plan by plan.

The 2027 Part B standard premium and deductible, and the 2027 IRMAA income brackets, hadn't been announced at this writing; CMS typically releases them in the fall. Separately, the Social Security Administration announced a 3.6% COLA for benefits payable beginning January 2027.

When you can enroll or change plans

• Annual Enrollment: October 15 – December 7, 2026, with changes effective January 1, 2027.
• If you have Medicaid or Extra Help: since 2025, you have a monthly Special Enrollment Period to move to Original Medicare with a stand-alone Part D plan, or to switch stand-alone Part D plans.
• If you're a full-benefit dual-eligible: you can join an integrated D-SNP in any month.

Where can you get help with Medicare questions?

For official plan details, enrollment windows and a plan finder, visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048, 24/7.