What is a plan type?
A plan type describes how a health insurance plan manages its network of providers, controls referrals, and shares costs with members. The main distinction is between network models (which structure how you access in-network vs. out-of-network care) and special-purpose plans (which add eligibility limits or delivery methods for specific populations or services). Understanding plan type helps you grasp what choices members have, how much flexibility they get, and what paperwork or authorization they might encounter.
Network Models
These describe the rules for accessing in-network and out-of-network providers:
HMO (Health Maintenance Organization)
Members must use in-network providers, except in genuine emergencies. Most HMOs require members to choose a Primary Care Physician (PCP) who coordinates care and issues referrals to specialists. Out-of-network care is usually not covered (except emergency). This structure typically means lower premiums and cost-sharing, but less flexibility.
PPO (Preferred Provider Organization)
Members can see any provider, in-network or out-of-network, without a referral. In-network care is less expensive (lower cost-sharing); out-of-network care is more expensive. Most PPOs do not require a Primary Care Physician. This model offers more flexibility and choice, with the trade-off of higher out-of-network costs and larger premiums.
EPO (Exclusive Provider Organization)
A middle ground between HMO and PPO. Members use in-network providers for non-emergency care (similar to HMO), but do not need a PCP or referrals (similar to PPO). Out-of-network care is usually not covered except emergencies.
POS (Point of Service)
Combines HMO and PPO features. Members must choose a PCP and can stay in-network for lower costs, but can also go out-of-network (with referral) and pay higher cost-sharing. Offers more flexibility than a pure HMO while maintaining some coordination through the PCP.
Medicare Drug & Medical Combinations
These plan types bundle medical and prescription drug coverage under Medicare:
MAPD (Medicare Advantage Prescription Drug)
A Medicare Advantage plan (HMO, PPO, or other network model) that includes Part D prescription drug coverage in a single plan. The member pays one set of premiums and cost-sharing, and the plan coordinates both medical and pharmacy benefits. Most Medicare Advantage enrollees are in MAPD plans.
PDP (Prescription Drug Plan)
A stand-alone Part D drug plan. Members use a PDP when they stay on Original Medicare (fee-for-service) for medical coverage. The PDP covers only prescription drugs; it does not cover medical services. A member must pair a PDP with Original Medicare or a Medigap policy to have complete coverage.
Special Needs Plans (SNPs)
These are a subset of Medicare Advantage plans designed for specific populations. Enrollment is limited to people who meet the eligibility criteria. SNPs are a form of managed care tailored to members with particular conditions, living situations, or dual coverage:
D-SNP (Dual-Eligible SNP)
For people with both Medicare and Medicaid. These plans coordinate benefits across both programs, helping manage eligibility, cost-sharing, and coverage gaps. D-SNP enrollment is limited to people who meet both Medicare and Medicaid eligibility rules in their state.
C-SNP (Chronic Condition SNP)
For people with specific severe or disabling chronic conditions (such as diabetes, heart disease, or chronic obstructive pulmonary disease). C-SNPs tailor their benefits, care coordination, and networks to support people managing these conditions. Enrollment is open only to people with a qualifying condition.
I-SNP (Institutional SNP)
For people who are living in or expected to be living in a nursing facility or institutional setting (such as a long-term care hospital), or who are receiving equivalent care at home. These plans are designed to coordinate institutional or high-touch care. Enrollment requires verification of institutional status or equivalent home care.
Medicaid Managed Care Delivery
States can deliver Medicaid benefits through managed-care plans or keep members in traditional fee-for-service. These are the main managed-care contract types:
MCO (Managed Care Organization)
A private health plan that a state contracts with to deliver Medicaid benefits to members. The state pays the MCO a monthly capitated (fixed) amount per member, and the MCO covers the member's medical services. MCOs manage a network of providers, benefits, and cost-sharing. The vast majority of Medicaid beneficiaries are enrolled in MCO plans.
PIHP & PAHP
Specialized Medicaid managed-care contracts. A PIHP (Prepaid Inpatient Health Plan) covers inpatient hospital and institutional care for a capitated fee. A PAHP (Prepaid Ambulatory Health Plan) covers outpatient and ambulatory services. These are used alongside MCOs to manage specific service lines in some states.
Long-Term Services and Supports
LTSS (Long-Term Services and Supports)
Help with activities of daily living (such as bathing, dressing, medication management, mobility) for people who cannot do them independently due to age, disability, or chronic illness. LTSS can be provided in institutional settings (nursing facilities, assisted living) or in members' own homes and communities. LTSS is funded by Medicare, Medicaid, private insurance, or out-of-pocket payment, depending on the program and the member's eligibility.
MLTSS (Managed LTSS)
LTSS delivered and coordinated through a managed-care plan (usually under Medicaid or Medicare Advantage). An MLTSS plan hires personal-care aides, manages home-care agencies, coordinates nursing, and arranges facility placement and benefits. MLTSS is growing as states seek to coordinate care and control costs for members with high LTSS needs.
Quick Reference Table
| Acronym | Full Name | One-Line Description |
|---|---|---|
| HMO | Health Maintenance Organization | In-network only; PCP required; referrals needed for specialists. |
| PPO | Preferred Provider Organization | In- and out-of-network; no referral required; more flexibility, higher out-of-network costs. |
| EPO | Exclusive Provider Organization | In-network only (like HMO); no referral required (like PPO). |
| POS | Point of Service | PCP model with in-network focus; can access out-of-network with referral and higher cost-sharing. |
| MAPD | Medicare Advantage Prescription Drug | Medicare Advantage plan that includes Part D drug coverage in one integrated plan. |
| PDP | Prescription Drug Plan | Stand-alone Part D drug coverage paired with Original Medicare or Medigap. |
| D-SNP | Dual-Eligible Special Needs Plan | Medicare Advantage plan for people with both Medicare and Medicaid eligibility. |
| C-SNP | Chronic Condition Special Needs Plan | Medicare Advantage plan tailored to people with specific chronic conditions. |
| I-SNP | Institutional Special Needs Plan | Medicare Advantage plan for people in or expected to enter institutional care or equivalent home care. |
| MCO | Managed Care Organization | Private health plan contracted by a state to deliver Medicaid benefits for a capitated monthly fee. |
| PIHP | Prepaid Inpatient Health Plan | Medicaid managed-care contract covering inpatient hospital and institutional services. |
| PAHP | Prepaid Ambulatory Health Plan | Medicaid managed-care contract covering outpatient and ambulatory services. |
| LTSS | Long-Term Services and Supports | Help with daily activities for people who cannot do them independently, in institutional or community settings. |
| MLTSS | Managed Long-Term Services and Supports | LTSS coordinated and delivered through a managed-care plan, typically Medicaid or Medicare Advantage. |
Important
Exact rules, network composition, eligibility restrictions, and cost-sharing vary by plan, plan year, and state. Do not assume that all HMOs, PPOs, MAPD plans, or MCOs work the same way. Always refer to the specific plan's official materials—summary of benefits and coverage, formulary, network directory, and evidence of coverage—to understand what a particular member's plan covers, which providers are in-network, and what their out-of-pocket costs will be. Eligibility for D-SNP, C-SNP, and I-SNP varies by state; check your state's Medicaid and Medicare guidance. For detailed information, visit Medicare.gov and Medicaid.gov.