What is a plan type?
A plan type describes how a health insurance plan works. It covers how the plan manages its doctors and hospitals, how it handles referrals (requests to see a specialist), and how it splits costs with members. There are two main kinds: network models (rules about seeing doctors in-network versus out-of-network) and special-purpose plans (plans for specific groups of people or types of care). Knowing the plan type helps you understand what choices members have, how free they are to pick their doctors, and what approval forms or paperwork they might need.
Network Models
These describe the rules for accessing in-network and out-of-network providers:
HMO (Health Maintenance Organization)
You must use doctors and hospitals in the plan's network, except in real emergencies. Most HMOs also make you pick a main doctor (a PCP). That doctor directs your care and refers you to specialists. Care outside the network is usually not covered. In return, HMOs tend to cost less each month and at the doctor. The trade is less choice about who you see.
PPO (Preferred Provider Organization)
Members can see any doctor or hospital, in-network or out-of-network, without asking for a referral first. In-network care costs less; out-of-network care costs more. Most PPOs do not require you to pick one main doctor. This plan gives you more freedom to choose your doctors, but you pay higher costs when you go out-of-network and higher monthly bills.
EPO (Exclusive Provider Organization)
A middle ground between HMO and PPO. Members must use in-network doctors and hospitals for non-emergency care (like an HMO), but do not need one main doctor or referrals (like a PPO). Out-of-network care is usually not covered except in emergencies.
POS (Point of Service)
Combines HMO and PPO features. Members must pick one main doctor (PCP) and can stay in-network to pay less. But they can also see out-of-network doctors if they ask the PCP first, though they will pay more out-of-pocket. This gives more freedom than a pure HMO while keeping a main doctor to coordinate care.
Medicare Drug & Medical Combinations
These plan types combine medical care 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 all in one plan. The member pays one set of monthly costs and doctor visit bills, and the plan handles both medical care and medicines. Most people on Medicare Advantage are in MAPD plans.
PDP (Prescription Drug Plan)
A stand-alone drug plan for Part D (prescription coverage). Members use a PDP when they stay on Original Medicare (fee-for-service, meaning they pay the doctor directly and Medicare pays back part of it) for medical care. The PDP covers only prescription drugs; it does not cover doctor visits or hospital care. A member must combine a PDP with Original Medicare or a Medigap policy (supplemental insurance) to have full coverage.
Special Needs Plans (SNPs)
These are Medicare Advantage plans (managed care) made for specific groups of people. You can only enroll if you meet certain requirements. SNPs are customized for people with specific health conditions, living situations, or who have both Medicare and Medicaid:
D-SNP (Dual-Eligible SNP)
For people who have both Medicare and Medicaid. These plans coordinate benefits across both programs. They help manage eligibility, out-of-pocket costs (coinsurance—your share of the bill), and gaps in coverage. You can only enroll if you qualify for both Medicare and Medicaid in your state.
C-SNP (Chronic Condition SNP)
For people with certain serious health conditions that last a long time. Examples are diabetes, heart disease, and COPD (a lung condition). These plans shape their benefits and doctor networks around the condition. You can only join if you have a condition that qualifies.
I-SNP (Institutional SNP)
For people who live or will live in a nursing home or other care facility (such as a long-term care hospital), or who receive similar care at home. These plans are made to coordinate care in facilities or provide hands-on home care. To enroll, you must prove you are in a facility or receiving equivalent home care.
Medicaid Managed Care Delivery
States can provide Medicaid benefits through managed-care plans or use the traditional way (fee-for-service, where the doctor bills and Medicaid pays). Here are the main types of managed-care plans:
MCO (Managed Care Organization)
A private health plan that a state pays to deliver Medicaid benefits. The state pays the MCO a fixed monthly amount per member, and the MCO covers the member's medical services. MCOs manage a network of doctors and hospitals, decide what is covered, and set out-of-pocket costs. Most people on Medicaid are in MCO plans.
PIHP & PAHP
Specialized Medicaid managed-care contracts. A PIHP (Prepaid Inpatient Health Plan) covers hospital stays and care in facilities for a set monthly fee. A PAHP (Prepaid Ambulatory Health Plan) covers doctor visits and outpatient services (care you receive without staying overnight). Some states use these alongside MCOs to manage specific types of care.
Long-Term Services and Supports
LTSS (Long-Term Services and Supports)
Help with daily tasks like bathing, dressing, taking medicines, and moving around. It is for people who cannot do these things alone because of age, disability, or illness. The help can come in a nursing home, in assisted living, or in the person's own home. Who pays — Medicare, Medicaid, private insurance, or the person — depends on the program and who qualifies.
MLTSS (Managed LTSS)
This is long-term daily help run through a managed-care plan, usually Medicaid or Medicare Advantage. The plan hires the aides who help with bathing and dressing. It also manages home-care agencies, nurses, and nursing home placement. More states now use this model to organize care and control costs for people who need a lot of long-term help.
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
Every plan is different. The rules, the networks, the costs, and who can join all change by plan, year, and state. Do not assume two HMOs or two PPOs work the same way. Always read the plan's own papers. Check the benefits summary, the drug list, the network directory, and the evidence of coverage. They show what is covered, which doctors are in the network, and what you will pay. Who can join a D-SNP, C-SNP, or I-SNP also differs by state. For more, visit Medicare.gov and Medicaid.gov.