How can you determine if your Medicare Advantage plan restricts you to network doctors?
Not every Medicare Advantage plan needs the use of doctors within its provider network, but a considerable number of them do. Some Medicare Advantage plans may permit you to seek medical care outside their network, but they might levy a higher coinsurance amount or copayment in such cases.
How do I find a primary doctor in my network?
Review your plan’s details and rules regarding coverage to determine if you must exclusively seek doctors who accept your Medicare Advantage plan.
What types of Medicare Advantage plans may demand network providers?
Here is a compilation of several common types of Medicare Advantage plans and whether they limit you to plan network providers.
Health Maintenance Organizations (HMOs) are a form of Medicare Advantage plan. HMO plans’ costs are sometimes lower than other Medicare Advantage plan types, but typically, you are confined to doctors within the plan’s provider network. Normally, you are required to select a primary care physician (PCP). Most plans include coverage for prescription drugs.
For HMO plans, you generally must receive your healthcare services from providers within your plan’s network, except for emergency care, out-of-area urgent care, and out-of-area dialysis. In certain cases, you may be able to use out-of-network services for specific needs, but it is usually more cost-effective to obtain care from a network provider.
Preferred Provider Organizations (PPOs) might charge you less if you utilize doctors in the plan’s network. While these plans generally allow seeking care outside the plan network, higher coinsurance or copayments may apply in such instances. Typically, you are not obligated to choose a primary care physician (PCP). Most plans include coverage for prescription drugs.
Private Fee-for-Service (PFFS) plans determine payment rates for providers and charges for certain covered services. You may be able to visit any doctor who accepts Medicare assignment and agrees to the terms of the PFFS plan. Some PFFS plans have provider networks that commit to accepting and treating plan members consistently. Additionally, some PFFS plans include prescription drug coverage.
Special Needs Plans (SNPs) usually require you to receive care and services from doctors or hospitals within the plan’s network, except in cases of emergency or urgent care or if you suffer from End-Stage Renal Disease (ESRD) and necessitate out-of-area dialysis. Typically, SNPs have specialists in the diseases or conditions that affect their members.
There are other types of Medicare Advantage plans as well; some may have provider networks where you might need to find a doctor who accepts the Medicare Advantage plan.
How much do Medicare Advantage plans cost?
The premiums, deductibles, copayments, coinsurance, and out-of-pocket limits for each plan may vary and can change annually. However, it is crucial to remember that to remain in your Medicare Advantage plan, you must have Medicare Part B and continue paying your Medicare Part B premium.
How do you know which doctors accept Medicare Advantage plans?
There are several methods to find doctors who accept your Medicare Advantage plan:
Check your Medicare Advantage plan’s website or call them to discover doctors who accept the Medicare Advantage plan.
If you have a specific doctor in mind for your care, contact their office or search for the doctor on your plan’s website.
To find a doctor who accepts Medicare assignment, you can use Medicare’s “Find Doctors” tool. This applies if your plan permits you to see doctors of your choice.
Again, review your plan information to determine whether you must find a doctor within the plan’s network.
*Please note: Out-of-network/non-contracted providers have no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. If you require an out-of-network service, you or your provider are encouraged to request a pre-service organization determination to ascertain if the plan will cover the service. For more information, including cost-sharing details for out-of-network services, please contact the plan’s customer service or refer to your Evidence of Coverage.
**A Private Fee-for-Service plan is not Medicare supplement insurance. Providers who do not contract with the plan are not required to provide treatment, except in emergencies.
Need help? Call Health Plans in Oregon: 503-928-6918. Our assistance is at no cost to you.
