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Does My Medicare Advantage Plan Restrict the Providers I Can Use?


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Summary:

Some Medicare Advantage plans may use provider networks in order to keep costs down. Medicare Advantage Private Fee-for-Service (PFFS) plans and Medicare Medical Savings Account plans don’t have provider networks.

Medicare Advantage plans vs. Original Medicare

Medicare Advantage (Medicare Part C) lets you get your Medicare Part A and Part B benefits through a private, Medicare-approved health insurance company. You’re still enrolled in the Medicare program when you’re in a Medicare Advantage plan.

Under Original Medicare, you’re not limited in the providers you can use. While your costs will usually be lower if you use providers that accept Medicare assignment, you can see any provider that accepts Medicare.

In contrast, some Medicare Advantage plans may use provider networks as a way to keep costs down. These plans negotiate rates with groups of doctors, hospitals, suppliers, and other health-care professionals to provide services for members. If your Medicare Advantage plan requires you to use in-network providers, your out-of-pocket medical costs may also be lower than with more flexible plans.

Medicare Advantage plans with provider networks

Some Medicare Advantage plans may have rules when it comes to the providers you can use.

  • Medicare Advantage Health Maintenance Organization (HMO) plans may require you to use network providers in most cases.
  • Medicare Advantage Preferred Provider Organization (PPO) plans may have “preferred” networks of doctors you can use with lower cost-sharing. However, you can typically see out-of-network providers, and possibly pay higher costs.
  • Medicare Advantage HMO Point-of-Service plans may be a happy medium between PPO and HMO Medicare Advantage plans. These plans have provider networks. However, they usually give you the choice to use non-network providers for some services, usually with higher out-of-pocket costs.

Medicare Advantage plans with greater provider choice

Not all Medicare Advantage plans limit your provider choice:

  • Medicare Advantage Private Fee-for-Service (PFFS) plans might let you use any provider that agrees to accept the plan’s payment terms. Your doctor must accept your plan’s payment terms each time you receive a service. Keep in mind that providers may also decide not to accept your plan, although they must treat you in emergencies. Some PFFS plans may have provider networks of doctors that have agreed to always treat plan members.
  • Medicare Medical Savings Account plans don’t have provider networks, and you can use any doctor or hospital that accepts your plan. These Medicare Advantage plans may also have providers contracted with them.

How do I look up providers that accept my Medicare Advantage plan?

If you’re already enrolled in a Medicare Advantage plan and want to find providers that accept your plan, you can find this information by:

  • Calling your Medicare Advantage plan (you can usually find the member services number on the back of your membership card).
  • Visiting your Medicare Advantage plan’s website. Many plans include provider directories where you can easily find doctors that accept your coverage.
  • Contacting a doctor or provider directly to ask if they accept your Medicare Advantage plan.

Keep in mind that in addition to provider networks, some Medicare Advantage plans may have other rules when it comes to getting coverage (such as referrals for specialist care). Always make sure to follow the rules of your Medicare Advantage plan, or your plan may not cover services.

Finding Medicare Advantage plans that accept my doctors

If you’re ready to start browsing for Medicare Advantage plan options in your area, you can start right now. The eHealth plan finder tool makes it easy to look up coverage choices in your zip code. Simply type in your zip code into the box on this page.

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