In a Medicare Advantage Plan and Can’t See Your Doctor?

Urgent Care Medicare

Can't see your primary care physician? Other options exist

If you’re enrolled in a Medicare Advantage plan for obtaining your health insurance coverage, then it is likely that you may be required to choose a primary care physician as a part of your overall health care services.
It is this individual that you will usually see when you go in for an annual check-up, as well as when you need an initial consultation for a long list of other health related ailments. Your primary care physician will also be the one who can refer you to a specialist if you require more in-depth care for various conditions.

How Your Primary Care Physician Fits Into Your Overall Health Care Mix

In many cases, Medicare Advantage plans are set up in a similar manner to an HMO (Health Maintenance Organization) or PPO (Preferred Provider Organization). For example, in most HMO plans, you typically are required to obtain care and services from providers that are listed in your plan’s network. (There are some exceptions, such as if you need emergency care, as well as the need for out-of-area urgent care, and / or out-of-area kidney dialysis). In some instances, you may be allowed to obtain care from an out-of-network provider. However, this care will usually cost more.

Medicare Advantage PPO plans also have a network of providers. In this type of plan, you will typically pay less if you use these providers, as versus going out of the network. A PPO plan will also not require you to choose a primary care physician.

Your primary care physician, or PCP, is the doctor who is responsible for managing your health care. Your PCP can also provide you with a referral to see a specialist if you need one. In most instances, if you are enrolled in an HMO and you do not consult with your PCP prior to visiting a specialist, then your managed care plan will not typically cover the cost of this care.

Depending on the health condition you are dealing with, there could be some other viable alternatives for you if you are unable to see your primary care physician. One option could be to visit a local urgent care center.

Urgent care centers primarily treat illnesses and injuries that require immediate care, but that are not serious enough to require an emergency room visit. These types of facilities may also be able to treat you – and prescribe medication – if you have come down with strep throat or other virus, as well as if you contract a mild case of the flu.

Over the past several years, urgent care centers have become extremely popular. One reason for this is their convenience, as well as their (usually) shorter wait times than a hospital emergency room. In many cases, the out-of-pocket cost for a patient can be less with an urgent care center than by receiving other forms of care.

Other Medicare Coverage Alternatives

If you are enrolled in Medicare as your health insurance coverage, you may also consider switching from a Medicare Advantage PPO plan that requires a PCP, to a Medicare Advantage PPO plan, or even to Original Medicare coverage.
In most cases, you will not be required to obtain a referral to see a specialist in a Medicare PPO plan. (However, if you use specialists that are listed in your PPO plan’s network, the cost of your covered services will generally be less than if you see a non-network specialist).

If you really don’t like the idea of having to go through your Primary Care Physician and / or other “gatekeeper” before you can visit a health care specialist, you could also consider switching from Medicare Advantage to Original Medicare (Medicare Part A and Part B).

As a fee-for-service type of program, Original Medicare will typically reimburse you for your care, regardless of where you go to obtain your care. There is also no PCP requirement if you are enrolled in Medicare Part A and Part B.

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Author Bio: Ben started Prepare for Medicare in 2014 to help people help people get objective answers to questions about Medicare. He’s held leadership roles at numerous Fortune 500 Medicare health insurers in product development, sales, marketing and strategy for over 20 years.