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Do Medicare providers prefer Medicare Advantage or Original Medicare?


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Maybe someone told you that you’ll get better care with Original Medicare vs Medicare Advantage or vice versa. Have you ever wondered if Medicare providers have a preference between Medicare Advantage plans and Original Medicare?

Let’s take a look at how Medicare providers are paid, whether they’re part of a Medicare Advantage plan or Original Medicare network.

Medicare providers and Original Medicare (Medicare Part A and Part B)

Original Medicare is made up of Medicare Part A (hospital insurance) and Medicare Part B (medical insurance).

  • Participating Medicare providers agree to accept Medicare payment, called “assignment.” This means the provider accepts Medicare payment and will charge only up to the amount that Medicare allows for services.
  • Non-participating Medicare providers can choose to accept or not accept Medicare assignment for individual services.
  • A doctor who doesn’t accept Medicare assignment may be legally allowed to charge more for a service than the Medicare-approved amount. In this case, the Medicare provider may be allowed to charge you an “excess charge.” An excess charge may be up 15% more than what Medicare allows for certain services.
  • Providers who have “opted out” of Medicare do not accept Medicare assignment at all and will not bill Medicare for your care. Unless you have other insurance, you will be responsible for the entire bill.

If you decide to receive your coverage through Original Medicare, you can choose any doctor or hospital who accepts Medicare payments, and Medicare will typically pay its portion for covered services. You don’t need referral authorizations to see specialists. Medicare providers will handle the paperwork of filing claims with Medicare on your behalf.

Medicare providers and Medicare Advantage plans

Some providers belong to Medicare Advantage plan networks. Medicare Advantage plans are offered by private insurance companies contracted with Medicare to provide at least the same benefits as Medicare Part A and Part B

Unlike Original Medicare, Medicare Advantage plans have regional service areas. In addition, they typically have networks of Medicare providers who are contracted with the Medicare Advantage plan and have an active, ongoing business relationship with the plan and other Medicare providers in the network.

Medicare Advantage plan networks must include hospitals, dialysis centers, primary care physicians, specialists, and other health-care professionals and suppliers.

However, Medicare Advantage plans don’t have to contract with every Medicare provider in their area. Instead, they contract with Medicare providers who agree to coordinating patient care, improving the quality of patient care, and accepting the Medicare Advantage plan’s reimbursement schedules and administrative rules.

There are different models of Medicare Advantage plans. The Medicare provider arrangement is a key factor distinguishing the models. Common models include:

  • Medicare Advantage Health Maintenance Organizations (HMOs) – Generally you must get non-emergency care from providers within the plan’s network to receive benefits for covered services. You select a participating primary care physician who coordinates your care, including referrals to specialists.
  • Medicare Advantage Preferred Provider Organizations (PPOs) – You can visit any doctor, hospital, or other health-care provider who takes Medicare assignment, but you usually pay less if you use providers who participate in the plan’s network.
  • Private For-for-Service (PFFS) Plans – If the plan has a network, you can see any Medicare provider who agrees to accept you as a patient. You can also be treated by any Medicare provider who is not in the network but who agrees to treat you and accept the plan’s payment terms. If the plan does not have a network, you can see any Medicare provider who agrees to treat you and accept the plan’s payment terms.
  • Special Needs Plans (SNP) –Special Needs Plans can be HMOs or PPOs. Special Needs Plans are designed for people with certain chronic conditions, those eligible for both Medicare and Medicaid, and those who may qualify by living in certain institutions, such as nursing homes. The network includes hospitals, pharmacies, physicians and other health professionals who specialize in treating chronic conditions. Usually you must receive non-emergency care from providers within the plan’s network to receive the highest level of benefits for covered services.

A Medicare Advantage plan will assist you to find suitable Medicare doctors and other health professionals in the network, as needed. If you have hospital and physician preferences, be sure to check to see if they are in the plan’s network.

If you enroll in a Medicare Advantage plan, your costs may be lower than if you stay with Original Medicare. You will pay your Part B premium, an annual deductible, if any, copayments and coinsurance. You may or may not pay another premium to the Medicare Advantage plan, depending on the plan you select.

Which do Medicare providers like better?

There may be something to be said for Medicare Advantage over Original Medicare from a Medicare provider’s point of view – or vice versa. Perhaps a new doctor who’s trying to build a practice might like a Medicare Advantage plan’s structure, allowing him or her to join a practice that’s already set up. Or, maybe some Medicare providers feel they have more flexibility under Original Medicare, where they’re not bound to network rules. Every Medicare provider may have his or her own reasons for deciding whether to join a Medicare Advantage plan’s network.

You can find Medicare Advantage plans where you live by entering your zip code. Or, you can call one of eHealth’s licensed insurance agents to discuss your Medicare coverage options and answer questions you may have.

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