Is My Doctor in My Medicare Network? Help!

Medicare HMO PPO Networks

Do your homework to make sure your doctor is in-network!

If you’re concerned you may have to switch your doctors when you have Medicare, you should be.  There are often differences between an Obamacare (ACA) or employer-based commercial insurance plan networks.  Without careful planning, you may just enroll in a plan that doesn’t include your doctor or hospital of choice.  Whether or not your doctor or hospital is in-network is an important factor in choosing your Medicare insurance coverage. You have the opportunity to contact several different Medicare Advantage plan providers and ask them questions about their in-network providers (and also their prescription formularies and any other questions you may have). Here’s where a really good independent insurance agent comes in handy.

Sticking With Original Medicare

Although we’ve covered the pros and cons of staying with the Original Medicare program for hospital and doctor coverage in our post, “Should I Stick With Original Medicare?” you may not have to change your doctor just because you get Medicare. If you stick with Original Medicare, you should have no problem continuing your care with your Primary Care Physician or Specialist you’re already seeing.  That’s because more than 90% of Primary Care Physicians (PCPs) accept Original Medicare, according to Kaiser.  

If you only have original Medicare, there is no network. Same goes for a Medicare Supplement plan – there IS no network.  You can go to any doctor who accepts original Medicare to get the price that Medicare has contracted. If they do not accept Medicare assignment –  beware! The doctor may ask you to pay in full and you may have higher out of pocket costs. You can find doctors who take Medicare assignment through this handy tool provided by Medicare.

Medicare Advantage Plan Networks

If you are looking at getting a Medicare Advantage plan, you should know some acronyms: HMO and PPO.

HMO plans typically work with you having one primary doctor, and that doctor refers you to your specialists. Your doctor and specialists typically need to be in network for you to have coverage. An HMO is a Health Maintenance Organization. If you visit a doctor, health care provider, or hospital outside of the HMO network, you will likely pay full cost for your services. To see a specialist with an HMO plan, you will most likely need a referral from your primary care doctor.

With PPO plans, you are free to see any doctor you choose. With PPO plans, there is a network of doctors, and when you stay in-network for services, you receive better coverage. If you go to see a doctor outside of the network, you still have coverage, but it’s not as good. Your coverage out of network is at a lesser rate than if you stayed with an in-network doctor.

If you’re in a Medicare Advantage plan your doctor does not participate in, what happens next depends on which plan you have!

An HMO plan will most likely have zero or very little out of network benefits. This can be verified by calling the phone number on the back of your insurance card and asking for someone in the benefits department. If your doctor isn’t in the network, all is not lost.  It only means your insurance won’t pay for your visit.  So, if you really want to go to this doctor, you will have to pay full-price, out of your own pocket.

A PPO plan is set up for people who want to see doctors outside of the network or who travel outside of the network.  Again, contacting the insurance company to see if you have a deductible and what your charges will be beforehand is a smart move before going out-of-network.

Do Medicare Advantage Networks Change or Stay the Same Every Year?

Networks usually change every month!   Doctors and physicians within the network must accept being a part of the network each year, but doctors and hospitals join and leave networks all the time.   When you have a network-based plan such as Medicare Advantage, we recommend calling your doctor’s office to verify they accept the plan’s coverage prior to re-enrolling for another year during AEP.

Use an Independent, Certified Insurance Agent

There’s an easy way of doing this, and there’s a hard way. The hard way is to do it yourself… look up all of the plans available in your area and call them. Ask them if your doctor or preferred hospital system is in their networks.

The easier way of doing this is have an insurance agent do it for you. Independent insurance agents representing Medicare Advantage and Medicare Prescription Drug companies must get trained and tested annually on Medicare compliance and regulation issues, including Medicare Advantage Plans and Prescription Drug Plans. They have a very good idea of the networks each company has, and can do a customized search for you. Once you’ve found your plan, they can help you enroll. To read more about independent insurance agents, we’ve previously posted a very comprehensive article here.

The Takeaway:

Just because you change from commercial insurance to Medicare doesn’t necessarily mean that you will lose your doctor. Many doctors accept Medicare assignment.  Make sure you are researching your doctor’s status with your network while you are choosing a Medicare Advantage plan during open enrollment. Also, ask about what you are responsible for if you go to a doctor that is outside of your network. Lastly, if you do not understand your benefits or coverage options, call the number on the back of your insurance card and ask!

Got a Medicare question? We love questions. Contact us.
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.