If you’re enrolled in Medicare for your health care, you may be required to use hospitals and / or medical professionals who are part of a particular network in order to have your services covered by your plan.
Depending on your specific Medicare coverage, using in-network providers and facilities can make a big difference in the overall out-of-pocket cost that you are required to pay for your health care and other related services. *Scroll down to the bottom of the post to access the Provider Search tools for major Medicare Advantage insurance companies.
The Medicare plan that you have will dictate whether or not you are required to use an in-network health care provider. For example, if you have Original Medicare (which is Medicare Part A and Part B), you are allowed to use any health care provider that you choose and that accepts Medicare assignment. * (Related Post – Medicare Supplement Plan F and the Medicare Excess Charge).
That is because Original Medicare is a fee-for-service program, meaning that in most cases, you can get your care from any Medicare-approved doctor, hospital or health care provider that accepts the plan’s payment terms, and that agrees to treat you. This holds true if you have a Medicare Supplement, or Medigap plan as well.
There are other types of Medicare plans that are more restrictive in terms of which doctors and providers you can use. These typically fall into the category of Medicare Advantage HMO (health maintenance organization) and PPO (preferred provider organization) plans.
Generally, a Medicare HMO (Health Maintenance Organization) plan will require that you get your health care services from medical facilities and providers that are listed in a given network. In this case, you will usually have a primary care physician (PCP), and you will need to obtain a referral from your PCP in order to see a specialist.
There are, however, some exceptions to the in-network requirement with a Medicare HMO plan. These exceptions will usually include getting urgent care or dialysis when you are out of your local area, as well as if you require emergency care.
There are also some Medicare HMO plans that may allow you to go out of your network to get care for certain services. However, by staying in your plan’s network, this same care will typically cost you less out-of-pocket.
To view a list of in-network health care providers, it is generally best to go directly through your Medicare HMO plan’s website and search for providers using their online search tools.*Scroll down to the bottom of the post to access the Provider Search tools for major Medicare Advantage insurance companies. In many cases, you can search your plan’s website to find more information about in-network doctors and facilities.
Another type of Medicare Advantage plan, a Medicare PPO (preferred provider organization) may also require at least some in-network requirements. In this case, you will pay less out-of-pocket if you receive your care from doctors, hospitals, and other providers that are included in the plan’s network as versus getting care from an out-of-network option.
There are also some other differences, too, between a Medicare HMO and a Medicare PPO plan. For instance, in a Medicare preferred provider organization, it is not typically required that you have a primary care physician (PCP).
Also, in a Medicare PPO, in most cases you do not have to obtain a referral in order to visit a specialist. And, if you see a specialist that is listed in the PPO plan’s list of in-network providers, the cost to you out-of-pocket will usually be less than if you use a specialist that is not included in the plan’s network.
As with the Medicare Health Maintenance Organization (HMO) plan, you can typically find more information regarding in-network PPO providers – including contact information – directly from your plan.
It is important to note that Medicare HMO and Medicare PPO plans are not the same as Original Medicare or Medicare Supplement insurance. While these Medicare Advantage plans will provide you with the same benefits that are in Medicare Part A and B, they will also oftentimes include additional covered items, such as vision, dental, and / or wellness services. You may also find that many Medicare Advantage plans include Medicare Part D prescription drug coverage.
Medicare SNPs, or Special Needs Plans, are another type of Medicare Advantage plan. An SNP, however, limits its membership to those who have certain health issues and / or who meet certain criteria (such as those who reside in a skilled nursing facility).
With this type of Medicare plan, it is usually necessary to obtain health care and other related services via providers that are listed in a network. There are, however, some exceptions to this rule. These exceptions include:
Similar to with a normal Medicare HMO plan, a Medicare Special Needs Plan will require that you obtain and work with a primary care physician (PCP) or a care coordinator who can assist you with your overall health care needs.
Also, other than with just a few exceptions, you will typically have to obtain a referral from your PCP in order to see a health care specialist. (Exceptions here include getting an annual mammogram screening, and a pap test and / or pelvic exam that is conducted by an in-network provider).
Just as with other types of Medicare Advantage plans that require services from in-network providers, a Medicare SNP plan will usually provide information online and / or in its literature that can help you to find the providers and services that you need.
When you search through Medicare’s website, there are actually several different ways that you can locate the information that you need. For example, you can search for a condition, a body part, or a specialty in your location.
For example, by typing in St. Louis, Missouri, as a location, and diabetes as a condition, a list of 20 different specialty providers comes up. Then, by clicking on Endocrinology and View Results, there are 85 individual providers listed, all within 15 miles of the location.
In addition, Medicare also offers a Physician Compare section on their website. Here you can compare physicians, as well as other clinicians who are enrolled in Medicare so that you are better able to make an informed decision with regard to your health care.This can be done directly via the Medicare website by visiting their website by clicking here.
Comparing physicians is easy when using the Physician Compare service. In order to begin your search, just simply enter your zip code, or city and state. Next, enter a search term such as the physician’s specialty or their name. Then, from the drop down menu, click Search. This will provide a list of clinicians or groups, based on your particular search criteria.
Medicare Advantage plans can have many “moving parts.” This includes the requirement by some Medicare Advantage plans to obtain your care from an in-network doctor or facility. Similarly, some of the Medicare Advantage plans that offer more leeway in your choice of providers may end up requiring a higher out-of-pocket costs for you.
With all of this in mind, it is important that you have a good understanding of what your Medicare Advantage plan does and doesn’t cover, as well as any care-related requirements that you may have.
One way to ensure that you’re following the plan’s rules is to carefully read over all of the documents and literature that you have about your plan. If you are unable to locate the physical copies, you may also be able to find the information that you need online. If you bought your policy with the help of an independent insurance agent who specializes in Medicare, they can be of assistance as well.