Provider networks refer to certain restrictions that apply to Medicare coverage. Generally, if you are enrolled in Original Medicare and have a Medicare Supplement plan, you can receive coverage from any provider that accepts Medicare. Provider networks generally apply to Medicare Advantage plans.
A Medicare provider network includes doctors, hospitals, and other healthcare providers. These providers are contracted with the plan and are approved to provide healthcare services to beneficiaries. Providers within a plan network provide healthcare services at reduced rates. This gives the providers a steady flow of patients, while the plan provider covers healthcare expenses at reduced rates.
Medicare Provider Networks
Medicare Advantage plans have provider networks with different rules. There are HMO plans, PPO, PFFS, and SNPs. A Medicare Advantage HMO plan requires in-network care. If you go out of network, you will cover the expenses out-of-pocket, unless it’s for urgent care, emergency care, or dialysis. With an HMO plan, you must also choose a primary care doctor and get referrals to see specialists. Because of this limit to specific providers, HMO plans are much cheaper than other plans.
Preferred Provider Organization plans offer more flexibility than HMO plans. They have a list of in-network providers but will cover part of the medical expenses if you go out of network. However, you will end up paying more if you get your care outside of your plan’s network. You also do not need to get referrals to visit a specialist and you don’t need to choose a primary care doctor. Even though these plans do offer more flexibility than HMO plans, they will be a bit more costly than HMOs.
For Special Needs Plans, the plans are tailored specifically to its members and require that the members use the in-network providers. Private Fee-for-Service plans allow you to visit any provider you want but offer more coverage if you visit in-network providers. Some PFFS plans do not have plan provider networks.
Out-Of-Network Care
There are certain situations where you can get coverage if you go out of network. For example, you can get out-of-network care during an emergency, if you need urgent care, or you need out-of-area dialysis. Medical emergencies include but are limited to choking, unstoppable bleeding, suicidal thoughts, poisoning, etc.
However, as mentioned previously, depending on the plan you choose, you could receive some coverage by going out of network even if it’s not for an emergency. But plans like HMOs will not provide coverage and you will have to pay those costs out-of-pocket.
Deciding on which plan is best for you regarding coverage is really up to you and how limited you want to be when it comes to specific healthcare providers. By choosing a plan that requires you to stay in-network, you will be paying less compared to a plan that allows you to receive care from an outside provider.
At Cornerstone Senior Advisors, we are experienced, independent agents who specialize in Medicare. So, if you’re having trouble making a decision on which Medicare Advantage plan is right for you and your needs, call us today at 316-260-3331. We will help you compare all your options and discuss every pro and con.