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Doctor, provider, & hospitals in Medicare Advantage Plans

Health Maintenance Organization (HMO) Plans

In HMO Plans, you generally must get your care and services from doctors, other health care providers, or hospitals in the plan's network, except:

  • Emergency care
  • Out-of-area urgent care
  • Out-of-area dialysis

In some plans, you may be able to go out-of-network for certain services, but it usually costs less if you get your care from a network provider. This is called an HMO with a point-of-service (POS) option.

Preferred Provider Organization (PPO) Plans

In most cases, you can get your health care from any doctor, other health care provider, or hospital in PPO Plans. PPO Plans have network doctors, other health care providers, and hospitals.

Each plan gives you flexibility to go to doctors, specialists, or hospitals that aren't on the plan's list, but it will usually cost less if you get your care from a network provider.

Private Fee-for-Service (PFFS) Plans

In some cases, you get your health care from any doctor, other health care provider, or hospital in PFFS Plans.

Note

You can go to any Medicare-approved doctor, other health care provider, or hospital that accepts the plan's payment terms and agrees to treat you. Not all providers will.

If you join a PFFS Plan that has a network, you can also see any of the network providers who have agreed to always treat plan members. You can also choose an out-of-network doctor, hospital, or other provider, who accepts the plan's terms, but your costs will usually be lower if you stay in the network.

Special Needs Plans (SNPs)

Generally, you must get your care and services from doctors or hospitals in the Medicare SNP network, except:

  • Emergency or urgent care, like care you get for a sudden illness or injury that needs medical care right away
  • If you have End-Stage Renal Disease (ESRD) and need out-of-area dialysis

Medicare SNPs typically have specialists in the diseases or conditions that affect their members.