Guide
HMO, PPO or Special Needs Plan? Medicare Advantage plan types explained
Medicare Advantage plans come in a few types, and the type decides the rules you live with: which doctors you can see, whether you need referrals, and what happens when you're away from home. Here's what each one means.
Last reviewed October 26, 2026. General information, not advice about any plan.
HMO vs. PPO
- Doctors
- HMO: Network only, except emergencies, out-of-area urgent care and dialysis
- PPO: In network costs less; out of network allowed, usually for more
- Primary care doctor
- HMO: Usually you choose one
- PPO: Not required
- Referrals to specialists
- HMO: Usually needed
- PPO: Not needed
- Away from home
- HMO: Mostly limited to emergencies and urgent care
- PPO: More flexibility, at out-of-network prices
- Cost
- HMO: Varies; out-of-network care isn't covered
- PPO: Varies; out-of-network care costs more
Some HMOs have a "point-of-service" option that covers some out-of-network care. Check the plan's own rules.
Special Needs Plans
Special Needs Plans (SNPs) are Medicare Advantage plans limited to people with specific needs. They include drug coverage.
- D-SNP (dual eligible)
- For people with both Medicare and Medicaid. Some combine both programs in one plan. More on having both.
- C-SNP (chronic condition)
- For people with certain chronic conditions, such as diabetes, heart failure or chronic lung disease. The plan's network and care team focus on that condition.
- I-SNP (institutional)
- For people who live in a nursing home or similar facility, or need that level of care at home.
Questions to ask about any plan
- Are all my doctors, hospitals and my pharmacy in network?
- Do I need referrals or approval (prior authorization) for the care I use most?
- What's the yearly out-of-pocket limit, in network and out of network?
- How are my prescriptions covered?
- What happens if I travel, or spend part of the year in another state?
A licensed agent can answer these plan by plan. Here's what to bring so they can.
Common questions
Is an HMO or a PPO better?
Neither for everyone. HMOs keep you in network and usually need referrals. PPOs let you go out of network, usually for more. If you see specialists often or travel, a PPO's flexibility may matter.
Can I see any doctor with a Medicare Advantage PPO?
You can see out-of-network doctors who agree to treat you, but you'll usually pay more, and in-network care costs less.
Who can join a Special Needs Plan?
Only people who qualify: those with both Medicare and Medicaid, certain chronic conditions, or who live in (or need the level of care of) a nursing home, depending on the plan.
Do all plan types cover emergencies anywhere?
In the U.S., yes: emergency and urgent care are covered out of network. Plans generally don't cover care outside the U.S.
Keep reading
- Medicare Advantage or Medigap? The questions that decide itNeither is better for everyone. How the two common Medicare set-ups differ, the questions that point to one or the other, and why the first choice is the hardest to undo.
- Have Medicare and Medicaid? What changes, and how an agent can helpIf you qualify for both Medicare and Medicaid, you have extra help with costs, special plans, and more chances to change coverage. What to know, the 2025 rule changes, and what to watch for.
- How a good agent compares Medicare drug plans (and how to check their work)The premium is the smallest part of a drug plan's cost. What an agent should check for each of your prescriptions, the 2025 changes that cap your costs, and how to double-check the comparison.
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