Medicare Advantage

Out-of-network care in Durham: what 2027 plans allow

For 2027, Durham is looking at 69 Medicare Advantage plans: 6 new, 11 gone since 2026, and 25 still here but changed on premium, deductible, plan type or name, 9 of them under a new name. Below, how the lineup shifted in Durham County and what to compare, with no plan ranked or recommended.

Durham, N.C. — As the Annual Enrollment Period opens for 2027 coverage, Durham residents comparing Medicare Advantage plans will see the same three letters again and again: HMO, HMO-POS and PPO. Those labels decide which doctors you can see, whether you need a referral, and what happens if you get care outside the plan's network. The window to switch runs October 15 through December 7, 2026, and any change you make takes effect January 1, 2027.

Durham is in Durham County, where CMS lists 69 Medicare Advantage plans from 11 carriers for 2027. By type, that breaks down to 22 HMO plans, 20 HMO-POS plans and 27 PPO plans. No carrier in the county is offering a Private Fee-for-Service (PFFS) plan for 2027, though PFFS is still a plan type under Medicare nationally.

What do HMO, HMO-POS, PPO and PFFS mean under Medicare Advantage?

These are the four main Medicare Advantage plan types, and they differ mainly in network rules, referrals and out-of-network coverage.

• HMO (Health Maintenance Organization): You generally must use doctors, hospitals and pharmacies in the plan's network. Many HMOs ask you to pick a primary care doctor and get a referral before seeing a specialist. Out-of-network care is usually not covered except for emergencies and urgent care.
• HMO-POS (Point of Service): An HMO with a limited "point-of-service" option. You can get certain services out of network, usually at a higher cost share. The exact services and rules vary by plan.
• PPO (Preferred Provider Organization): You can see any Medicare-approved provider that accepts the plan, in or out of network. Out-of-network care is covered but typically costs more. Referrals usually are not required.
• PFFS (Private Fee-for-Service): You can see any Medicare-approved provider who agrees to the plan's payment terms. Referrals are not required. No PFFS plans are listed in Durham County for 2027.

None of these is "better" on its own. The right type depends on who your doctors are, whether you travel, and how much flexibility you want.

How many HMO, HMO-POS and PPO plans are offered in Durham County for 2027?

Durham County will have 22 HMO plans, 20 HMO-POS plans and 27 PPO plans in 2027, out of 69 Medicare Advantage plans total from 11 carriers. If you count HMO and HMO-POS together, 42 of the 69 plans use some form of HMO structure.

That is a modest shift from the current year. For 2026, Durham County has 74 Medicare Advantage plans from 12 carriers — 25 HMO, 19 HMO-POS and 30 PPO. For 2027, CMS data show 11 plans not returning, 6 new plans and 9 renamed. The table below lists every plan available in the county.

Which carriers offer HMO plans in Durham County for 2027?

Eight carriers offer HMO plans in Durham County for 2027: Aetna (CVS Health), Blue Cross and Blue Shield of North Carolina, HealthSpring, Humana, Liberty Medicare Advantage, Longevity Health Plan, PruittHealth Premier and Troy Medicare.

HMO plans tend to work well for people whose regular doctors are already in one local health system and who do not expect to need care while traveling outside the area. If a provider you rely on is not in a given HMO's network, that plan may not be a good fit — networks differ from carrier to carrier and can change year to year.

Which carriers offer HMO-POS and PPO plans in Durham County for 2027?

Four carriers offer HMO-POS plans in Durham County for 2027: Blue Cross and Blue Shield of North Carolina, Centene (WellCare), Humana and UnitedHealthcare.

Seven carriers offer PPO plans for 2027: Aetna (CVS Health), Blue Cross and Blue Shield of North Carolina, Centene (WellCare), HealthSpring, HealthTeam Advantage, Humana and UnitedHealthcare.

PPO plans generally give you the most flexibility to see providers outside the network, which can matter if you split time between Durham and another part of the country, or if you want the option to see a specialist without a referral. HMO-POS sits in the middle: mostly an HMO, with a defined out-of-network option for certain services spelled out in the plan documents.

What should Durham residents check before the December 7 deadline?

Start with your Annual Notice of Change (ANOC), which your current plan mailed in September. It lays out what is changing in 2027 — premium, drug list, provider network, copays and more. If your plan is one of the 11 not returning to Durham County in 2027, you will need to pick a new plan or you will be moved back to Original Medicare.

A few 2027 figures CMS has already published that apply to Part D drug coverage inside most Medicare Advantage plans:

• The Part D out-of-pocket cap rises to $2,400 in 2027 (up from $2,100 in 2026).
• The Part D maximum deductible rises to $700 in 2027 (up from $615 in 2026).

The 2027 Part B standard premium and deductible, and the 2027 IRMAA income brackets, have not been announced yet; CMS typically publishes them in the fall.

To compare specific plans — premiums, copays, drug lists, provider networks and star ratings — use the Medicare Plan Finder at medicare.gov or call 1-800-MEDICARE (TTY 1-877-486-2048), available 24 hours a day, 7 days a week. Each plan's Evidence of Coverage and provider directory have the authoritative details.