Many Medicare Advantage plans use provider networks that determine which doctors, specialists, hospitals and other healthcare providers you can use—and what you pay when you use them.
Medicare Advantage HMOs generally require you to receive non-emergency care from providers inside the plan’s network.
Medicare Advantage PPOs generally allow you to receive covered care outside the network, but you will usually pay more.
Understanding the network is critical before enrolling in a Medicare Advantage plan.
A network is a group of:
that have contracted with a Medicare Advantage plan.
Using providers inside the network generally gives you the plan’s preferred coverage and cost sharing.
With a Medicare Advantage HMO, you generally must use providers and facilities inside the plan’s network for non-emergency care.
Exceptions typically include:
Some HMO Point-of-Service plans may allow limited out-of-network care at higher cost.
If you receive non-emergency care outside an HMO network without the required authorization, you may have to pay the full cost.
How a PPO Network Works
With a Medicare Advantage PPO, you generally have more flexibility.
You can typically:
Use in-network providers at the lower cost
or
Use out-of-network providers for covered services at a higher cost
The provider must still be willing and eligible to provide the service under Medicare and plan rules.
HMO vs. PPO
HMO
Network restriction: Stronger
Out-of-network: Generally not covered except certain situations
Primary-care doctor: Usually
Specialist referral: Usually
Cost: Often lower in network
PPO
Network restriction: More flexible
Out-of-network: Usually available at higher cost
Primary-care doctor: Generally not required
Specialist referral: Generally not required
Cost: Out-of-network usually higher
What If Your Doctor Leaves the Network?
Medicare Advantage provider networks can change.
Plans have requirements to notify affected members in certain circumstances, but you may need to find another provider within the plan network.
This is why checking your provider network shouldn’t be a one-time exercise.
Medicare Advantage Networks: What You Need to Know
One of the biggest mistakes I see is someone asking:
“Does my doctor take Medicare?”
That’s not enough if you’re joining Medicare Advantage.
The better question is:
“Is my doctor in this specific Medicare Advantage plan’s network?”
And don’t stop with your primary doctor.
Check:
Specialists
Hospital
Cancer center
Cardiologist
Surgeon
and any other provider that would matter if your health changed.
A $0-premium plan isn’t much of a bargain if the doctors or hospitals you want aren’t in the network.
Medicare Advantage plans cover Medicare-covered cancer treatment, including qualifying chemotherapy, but plan networks, prior authorization rules and out-of-pocket costs can become especially important when someone has cancer.
Medicare’s Annual Enrollment Period, also commonly called Medicare Open Enrollment, runs, October 15 through December 7 each year.
Medicare on Video can help you compare Medicare coverage based on provider access, cost and the plans available where you live.
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