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What if My Medicare Doctor Isn’t in My Plan Network?

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If you have Original Medicare (Part A and Part B) you can generally visit any doctor who accepts Medicare. However, if you have certain types of Medicare Advantage plans, you may have to visit Medicare doctors that are in network or else pay more for your care.

What is a Medicare doctor network?

Generally, a network is an interrelated group or system. A Medicare doctor network is a group of doctors who have agreed to work with your health insurance plan. A network can be a good thing in the way that you know your plan has screened the network Medicare doctors. A network can also be a bad thing in the way that it can limit the doctors that you can see.

Do all Medicare Advantage plans have Medicare doctor networks?

There are four main types of Medicare Advantage plans, which handle networks differently.

Health Maintenance Organizations and Special Needs Plans have stricter regulations on networks.

  • Health Maintenance Organization (HMO) plans are restrictive about your seeing Medicare doctors in network. In an HMO plan you generally must get care and services from a Medicare doctor in network unless it is emergency care, out-of-area urgent care, or out-out-are dialysis. You may be able to go out of network for certain services, for example, if you need to see a specialist and the plan doesn’t cover the type you need to see in your area. Generally, if you have an HMO plan you pay less if you get care from a network Medicare doctor.
  • A Special Needs plan (SNP) is like an HMO in the way that you can only go out of network for emergency and urgent care, or if you traveling and need out-of-are dialysis.

PPO and PFFs have more relaxed regulations on networks.

  • Preferred Provider Organization (PPO) plans have networks, but you can you generally get care from any Medicare doctor. Like HMO plans, you will generally pay less if you go to a network provider.
  • Private Fee-for-Service (PFFS) plans are like PPO plans in the way that you can generally see any Medicare doctor or go to any hospital. You can also go to an out of network provider that accepts that plan’s terms, but you usually pay less if you stay in the network.

What should I do if my Medicare doctor is not in network?

If you have an emergency, seek medical attention as soon as possible. The law mandates that both private and public hospitals treat you in an emergency, regardless if the Medicare doctors or hospitals are in your network. With some plans, you have the options of seeing non-network Medicare doctors for non-emergencies but just paying more. If you think a non-network doctor should be added to your network, contact your plan. If you would like to change your plan to one that covers your provider, you can begin by entering your zip code on this page.

The provider network may change at any time. You will receive notice when necessary.

Out-of-network/non-contracted providers are under no obligation to treat Preferred provider Organization (PPO) plan members, except in emergency situations. For a decision about whether the plan will cover an out-of-network service, you or your provider are encouraged to ask for a pre-service organization determination before you receive the service. Please call the plan’s customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

A Private Fee-for-Service plan is not Medicare supplement insurance. Providers who do not contract with the plan are not required to see you except in an emergency.

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