Are Your Doctors in Network?
Why Networks Matter
Understanding your network is important to getting the care you need and avoiding surprise costs.
When you’re shopping for Medicare coverage, it’s important to understand the health plan’s network – the doctors, hospitals, pharmacies and other healthcare providers that a plan contracts with to provide care to you at a lower cost. Make sure your doctors and other care providers are in your plan’s network to avoid paying more.
With a Medicare Advantage Plan, there are two types of networks to consider. With a Medigap plan there are no networks – you can choose any doctor that accepts Medicare.
Medicare Advantage plans
If you enroll in a Medicare Advantage plan, you could have either a Health Maintenance Organization (HMO) plan or a Preferred Provider Organization (PPO) plan. HMO and PPO networks work differently.
HMO plans
With an HMO plan, you must get your care and services from doctors and providers in the plan's network. If you use a healthcare provider outside the HMO network, the plan may not cover the cost. The exception is for emergency care, out-of-area urgent care or out-of-area dialysis.
Most HMO plans require you to choose a primary care doctor, so if your doctor isn’t in the network, you’ll have to find a new one. You’ll also need to get a referral to see a specialist.
HMO-POS plans allow you to see providers outside of the network (non-contracted providers). However, while the plan will pay for certain covered services, the provider must agree to treat you. Except in an emergency or urgent situation, non-contracted providers may deny care. In addition, you may pay a higher co-pay for services provided by non-contracted providers.
HMOs usually have lower or no premium, but fewer doctors are in the network, so if you like your doctors and want to keep them, make sure they are in the network.
PPO plans
A PPO plan is designed to give you more flexibility in choosing doctors. PPO plans have a network of “preferred” doctors, hospitals and other providers, and in most cases you can get healthcare from anyone in the network. If you see a doctor or provider that’s not part of the PPO network, you may pay a higher copay, deductible, or have less coverage.
PPOs don’t require you to choose a primary care doctor, and in most cases, you don’t need a referral to see a specialist. You’ll have a larger network of doctors and providers to choose from, but you’ll probably pay a higher monthly premium than with an HMO plan.
Are your doctors in network?
When you’re shopping for a Medicare Advantage plan using our plan recommendation tool, we’ll ask you to provide the names and locations of your doctors and other healthcare providers. Be sure to include this information so that we can recommend plans that include your doctors in network.
Medicare Advantage networks can change, or your doctor can leave a network anytime, so it’s always a good idea to check with your doctor to make sure they’re still in your network.
If you’re already enrolled in a Medicare Advantage plan and want to visit a new doctor, make sure they’re in-network before your appointment. You can either call and ask the doctor’s office or check your insurance plan’s website. Most plans have a doctor finder tool you can use to find this information.
Medigap plans
If you have a Medigap plan, you can see any doctor that takes Medicare; these plans don’t have networks. If your doctor doesn’t accept Medicare, you may pay more, so be sure to ask before you make an appointment. If your doctor has opted out of Medicare, ask for a referral to a doctor who is in the Medicare program.
If you have a Medigap plan, you generally don’t have to choose a primary care doctor or have a referral to see a specialist. And if you travel a lot or live part-time in a different state, a Medigap plan gives you the flexibility to choose doctors in any state that accepts Medicare – no need to worry about staying in a network.
To find out if your doctor accepts Medicare, you can either call the doctor’s office and ask, or use the Medicare.gov physician compare tool. This tool will help you see which doctors in your area accept Medicare.
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