What is a Medicare Provider Network?
A Medicare provider network generally applies to certain Medicare Advantage plans. If you have Original Medicare (Part A and Part B), you typically can receive care from any Medicare provider that accepts “assignment.” Assignment means that the provider accepts the Medicare-approved amount as full payment for covered services.
Medicare Supplement (Medigap) plans also generally don’t have networks. Medicare Supplement plans may cover some out of pocket costs that Original Medicare doesn’t cover, such as deductibles, copayments, and coinsurance. One type of Medicare Supplement insurance plan, called Medicare SELECT, may have Medicare provider networks.
However, if you’re interested in getting a Medicare Advantage plan, or have already enrolled in one, here’s what you need to know about Medicare provider networks.
What is a Medicare provider network?
“Network” according to Merriam-Webster is an “interconnected chain, group, or system.” A Medicare provider network usually includes:
- Other health care providers, such as speech pathologists or occupational therapists
These providers contract with the plan to provide care to the plan’s members. While a Medicare provider network may have some restrictions, the benefit of the network is that it sometimes keeps your medical costs lower.
What kinds of Medicare Advantage plans have Medicare provider networks?
Most Medicare Advantage plans have Medicare provider networks but different rules on how you use them.
More restrictive plans include:
- HMO plans
- SNP plans
Less restrictive plans include:
- PPO plans
- PFFS plans*
A Medicare Advantage Health Maintenance Organization (HMO) plan generally requires you to get care from network providers except for emergency care, out-of-area urgent care, and out-of-area dialysis.
A Medicare Advantage Special Needs Plan (SNPs) generally limits care to doctors or hospitals in the Medicare SNP network, except emergency and urgent care and out-of-area-dialysis.
A Medicare Advantage Preferred Provider Organization (PPO) plan gives you a choice to visit doctors, specialists, and hospitals that aren’t in the plan’s Medicare provider network, but you generally will pay less if you receive care from a network provider.
A Medicare Advantage Private Fee-for-Service (PFFS) plan, like a PPO plan, may give you a lot of flexibility about which Medicare providers you visit, but also may have lower costs if you stay in the network (if the plan has one). If the plan doesn’t have a network, you may want to confirm with the Medicare provider that she or he accepts the PFFS plan’s payment terms. You may need to do this every time you see the doctor.
Do I need to stay within my Medicare provider network in an emergency?
According to federal law, you are not limited to your Medicare provider network in an emergency. The closest hospital should treat you regardless if it is an out-of-network hospital. According to the American College of Emergency Physicians, warning signs of a medical emergency include (but are not limited to):
- Unstoppable bleeding
- Suicidal thoughts
- Sudden, severe pain anywhere in the body
- Swallowing a poisonous substance
What if I go out of network for non-emergency care?
In some cases, you may choose to seek care outside of your Medicare provider network. For example, maybe there is a family counseling therapist that you have great rapport with, or a dermatologist that you’ve been seeing for decades before you were eligible for Medicare. You generally can still see these providers but may pay more out-of-pocket for your care. If you think that a non-network Medicare provider should be added to your network, contact your plan.
To look for a Medicare Advantage plan with a Medicare provider network in your area, enter your zip code on this page.
*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.