Medicaid Plans: PPO, HMO, and Other Network Types Explained

Medicaid is both PPO and HMO, depending on your state and plan

Medicaid does not operate as a single network type nationwide. Your state's Medicaid program offers one or more plan types — most commonly HMO (Health Maintenance Organization), PPO (Preferred Provider Organization), or POS (Point of Service) — and which one you get depends on where you live, which Medicaid category you fall into, and sometimes your choice during enrollment.

Some states run only HMO plans. Others offer a mix. A few allow you to pick. The key difference: HMO plans require you to choose a primary care doctor and stay within a network; PPO plans let you see any doctor without a referral but charge more if you go out of network. On Medicaid, the cost difference to you is usually smaller than in commercial insurance because Medicaid sets the rates.

Key Takeaways

Your state Medicaid program decides which plan types are available; not all states offer both HMO and PPO options.
HMO plans require a primary care doctor and referrals to see specialists; PPO plans do not, but may have higher copays for out-of-network care.
You may be automatically assigned to a plan or given a choice during open enrollment, depending on your state.
Switching plans is usually possible once a year during open enrollment, or immediately if you have a may have access to life event.

How HMO plans work on Medicaid

An HMO plan assigns you to a primary care doctor (PCP) who coordinates all your care. To see a specialist, you need a referral from your PCP first. All doctors and hospitals must be in the plan's network, and you pay nothing or a small copay for in-network visits. If you go to an out-of-network provider without an emergency, Medicaid will not pay.

HMO plans are the most common Medicaid option because they tend to cost the state less to run. States like California, New York, and Texas use HMO plans as their primary or only Medicaid managed care model. You do not choose your PCP — the plan assigns one — but you can usually request a change if you are unhappy.

The trade-off is less flexibility. You cannot walk into a dermatologist's office without a referral, and you cannot see an out-of-network doctor except in emergencies. For people who have a regular doctor and do not travel, this is usually not a problem. For people who move frequently or need specialists not in the network, it can be frustrating.

How PPO plans work on Medicaid

A PPO plan lets you see any doctor or specialist without a referral and without choosing a primary care doctor first. You pay a copay for in-network providers (usually $0 to $5 on Medicaid) and a higher copay or coinsurance for out-of-network providers. Unlike HMO plans, you are not locked into a network — you just pay more if you leave it.

PPO plans are less common on Medicaid than HMO plans, but some states offer them as an option. They appeal to people who have established relationships with doctors outside a plan's network, who travel, or who want the freedom to change doctors without asking permission. The downside is that out-of-network costs can add up, even though Medicaid covers a portion.

On Medicaid, the difference in your out-of-pocket cost between in-network and out-of-network is usually smaller than in commercial PPO plans because Medicaid negotiates rates directly with providers. Still, going out of network costs you more than staying in.

POS plans and other Medicaid network types

Some states offer a POS (Point of Service) plan, which is a hybrid. You choose a primary care doctor like in an HMO, but you can see out-of-network doctors without a referral — you just pay more. POS plans give you more flexibility than HMO but less than PPO, and they are less common than either.

A few states also offer FFS (Fee-for-Service) Medicaid, where you can see any doctor who accepts Medicaid without joining a managed care plan at all. The state pays the provider directly for each visit. FFS is becoming rarer as states move toward managed care, but it still exists in some places, usually as an option for people with complex medical needs or those who cannot be assigned to a managed care plan.

How your state assigns you to a plan

When you are approved for Medicaid, your state either assigns you to a plan automatically or gives you a choice during enrollment. If you are assigned, you receive a notice in the mail with your plan name, member ID, and your assigned primary care doctor (if it is an HMO). You have a window — usually 30 to 60 days — to request a different plan if you want one.

If your state lets you choose, you will receive information about available plans before your coverage starts. You can compare networks, copays, and covered services, then pick the one that works best for you. The choice period is usually during open enrollment (once a year) or when you first become Medicaid-may be able to access.

Some states auto-assign you to an HMO and let you switch to a PPO if one is available. Others require you to stay in the plan you chose for a full year. Check your state Medicaid website or your enrollment notice to see what applies to you.

Changing plans if you are unhappy with yours

You can usually change Medicaid plans once a year during open enrollment, which runs from November through mid-January in most states. You can also switch immediately if you have a may have access to life event: moving to a new state, losing other insurance, having a baby, or a significant change in income.

To switch, contact your state Medicaid office or your current plan and ask to disenroll. You will be given a list of available plans and a deadline to choose. Your new coverage starts on the first of the following month. If you do not choose during open enrollment and do not have a may have access to event, you are locked into your current plan for another year.

Frequently Asked Questions

Can I see any doctor I want on Medicaid HMO?

Only doctors in your HMO plan's network. You must use your assigned primary care doctor for routine care and get a referral to see specialists. If you see an out-of-network doctor without an emergency, Medicaid will not pay. You can request a different primary care doctor within the network if you are unhappy.

Do I have to pay more to see an out-of-network doctor on Medicaid PPO?

Yes, usually. In-network visits are typically free or a small copay. Out-of-network visits usually have a higher copay or coinsurance. Medicaid still covers part of the cost, but you pay more than you would in-network. Check your plan's summary of benefits to see the exact amounts.

What happens if my doctor is not in my Medicaid plan's network?

If you are in an HMO, you will need to switch to a doctor in the network or request a network exception from your plan (which is sometimes granted if no in-network doctor has your specialty nearby). If you are in a PPO, you can keep seeing that doctor but will pay a higher copay. You can also switch to a different Medicaid plan during open enrollment if another plan includes your doctor.

Can I switch from HMO to PPO on Medicaid?

Only during open enrollment (November through mid-January) or if you have a may have access to life event like moving or losing other insurance. If your state offers both plan types, you can request the switch. If your state offers only HMO, you cannot switch to PPO because it is not available. Check your state Medicaid website to see which plans are offered where you live.

This guide is for general information only and is not medical, financial, legal, or other professional advice. For decisions specific to your situation, consult a qualified professional. See our Editorial Policy.