When it comes to health care services, it’s important to have options. After all, what if you need to pick a new primary care doctor or see a specific type of specialist?
To keep costs low, staying within your Medicare plan network can make all the difference – especially for those with a Medicare Advantage plan.
Here’s what you need to know about the cost of health care in and out of network, different kinds of Medicare plan networks and how to change or find new doctors who accept Medicare.
What is a Medicare plan network?
A health insurance network is a group of doctors, hospitals, clinics and other providers who are partnered with your insurer to provide plan members with health care services. Using a doctor who is in your plan’s network can help you save money and get the most value for your care.
Most Medicare Advantage and Cost plans have individual, tailored networks. And while all Medicare Advantage plans cover out-of-network care for emergencies or urgent care, each has different network guidelines. These outline how you can receive care from a specialist or out-of-network provider.
It’s important that you understand your plan’s network and coverage options before enrolling. If you have any questions, contact your plan’s service team to ask about providers and network coverage availability.
Does Original Medicare have a network?
Original Medicare (Parts A and B) does not have a network – at least not in the traditional sense. However, if you are a Medicare recipient, you can go to any doctor, clinic or provider who accepts Medicare.
What kinds of networks do Medicare Advantage plans have?
Network options are different based on the type of Medicare Advantage plan you are shopping for. In most cases, you’ll need to use providers who are in the plan’s network. Some networks have many providers, and some have less. But what will work best for you? First, it’s important to narrow down your health care and coverage needs. Here are the most common types of Medicare Advantage plans and what you can expect from their networks.
- Health maintenance organization (HMO) plans generally have smaller networks with a select group of providers. You must get your care and services from providers in this network, although some plans may allow you to go out of network for certain services. These are called HMO with a point-of-service (POS) plans.
- Preferred provider organization (PPO) plans generally have a larger network than HMO plans and give you the flexibility to get care from any provider in the network. All plan services are covered in and out of the network. However, out-of-network providers may be more expensive – though some PPOs may have the same copays and coinsurance for care, whether it’s in or out of network. PPOs may require a referral to see a specialist.
Most Medicare Advantage plans include prescription drugs and will also have a pharmacy network. These networks are large and often include national pharmacies, as well as mail order. Generally, your plan only covers prescriptions filled at an in-network pharmacy. And if your plan offers a preferred pharmacy, your out-of-pocket costs may also be less.
Why is it important to choose a provider that’s in my Medicare network?
In most cases, receiving care within your Medicare network is more affordable. Services offered by an in-network doctor are supported by your plan. If you go to a health care provider who’s not in your network, depending on your plan’s network guidelines, you’ll probably have to pay more out of pocket.
A comprehensive health network is also an important intersection between care and coverage, often ensuring better health outcomes. When plans work with groups of providers, they can better ensure the overall health and well-being of patients and plan members.
Also, many Medicare Advantage plans offer out-of-network benefits, even if you do have to pay more for those services. They also have a limit on how much you pay for covered medical services each year, which is known as the maximum out-of-pocket amount. This amount is typically higher for care you get out of the network.
How to find and change doctors on Medicare
For those with Original Medicare, finding a doctor who accepts Medicare is easy. To get started, you can go to Medicare.gov and see if the doctor you’re considering offers services to Medicare beneficiaries. You can also call the federal Medicare program directly for help. Once you find a doctor and have decided to move forward with care, your next step will be filling out a change of care form.
For Medicare Advantage plan members, your insurer should have a provider and pharmacy network directory with doctors, hospitals and pharmacies listed. This can be found online through your insurer’s website and will clearly list your plan’s Medicare in-network providers. If not, you can call your insurance provider’s member services – this number is usually provided on the back of your ID card.
HealthPartners members: You can contact your Member Services team with any network questions.
Does Medicare have out-of-network benefits?
Some Medicare Advantage plans have out-of-network benefits, but it really depends on your plan. Every plan has its own unique guidelines set by providers. Similarly, Medicare Cost plans have tailored networks. However, if you go out of your Cost plan’s network, your Original Medicare benefits will kick in, so you’ll be responsible for the Part A or Part B coinsurance and deductibles for care.