If you have a Medicare Advantage plan, one of the most important questions is simple: Can I keep my doctor?
The answer depends on your plan, its provider network, and the type of Medicare Advantage plan you have. Understanding how networks work can help you check your doctors before choosing a plan and know what to do if a provider leaves your network during the year.
What Is a Medicare Advantage Provider Network?
A provider network is a group of doctors, hospitals, specialists, and other healthcare providers that have agreements with a Medicare Advantage plan.
When you have Medicare Advantage, you remain enrolled in Medicare, but you receive your Medicare Part A and Part B benefits through the Medicare Advantage plan.
Many Medicare Advantage plans use provider networks. Whether you can receive covered care outside that network depends largely on the type of plan you have.
HMO and PPO Plans Work Differently
Two common types of Medicare Advantage plans are Health Maintenance Organization (HMO) plans and Preferred Provider Organization (PPO) plans.
HMO Plans
HMO plans generally require you to receive non-emergency care from providers in the plan's network. There are exceptions for emergency care, out-of-area urgent care, and temporary out-of-area dialysis.
Some HMO plans include a point-of-service option that allows certain services outside the network, usually with higher cost sharing. Check your specific plan's rules to understand what is covered.
PPO Plans
PPO plans also have provider networks, but they generally provide more flexibility to receive covered services outside the network.
You usually pay less when you use an in-network provider and more when you receive covered care outside the network. Before receiving out-of-network care, check your plan's rules and confirm that the provider can see you under your plan.
How Do You Know If Your Doctor Is in Network?
Start with the plan's provider directory. Most plans have an online directory where you can search for doctors, hospitals, and specialists.
But don't stop there. Provider networks can change during the year. It is a good idea to confirm with both the provider's office and your plan before you schedule care.
Be specific about the exact plan name. An insurance company may offer several Medicare Advantage plans, and a doctor might participate in one network but not another.
You may also want to check the hospitals and specialists connected with your primary care doctor. In some plans, choosing a primary care doctor can affect which hospitals or specialist groups you use.
What If Your Doctor Leaves the Network?
Provider networks can change during the year. A doctor may retire, relocate, or end a contract with the plan.
If a provider you regularly see leaves your network, your plan may be required to give you advance notice depending on the circumstances. Medicare Advantage plans must also meet requirements for access to covered medical services.
A doctor leaving the network does not automatically create a Special Enrollment Period (SEP) that allows you to change plans. Certain significant changes to a plan's provider network may create additional enrollment options, but those situations depend on the circumstances and should not be confused with a single provider leaving a network.
If your doctor leaves, review the notice from your plan and the options that apply to your situation.
Check More Than Your Primary Care Doctor
Your primary care doctor is important, but may not be the only provider you want to consider when comparing Medicare Advantage plans.
Make a list of your specialists, preferred hospitals, and other providers you rely on. If you see several specialists, checking all of them can give you a better picture of whether a plan's network fits your healthcare needs.
Review Your Provider Network Each Year
Medicare Advantage plans can change from year to year, and provider participation can change too.
During the Annual Enrollment Period (AEP), from October 15 through December 7, review the provider network for the coming year. Don't assume that a doctor who is in network this year will automatically be in network next year.
Your Annual Notice of Change (ANOC) explains important changes to your current plan for the following year, but checking your doctors, specialists, and preferred hospitals separately is still an important part of reviewing your coverage.
The Bottom Line
If keeping your doctors is important to you, provider networks should be part of your Medicare Advantage review.
HMO plans generally require in-network care for non-emergency services. PPO plans usually offer more flexibility to receive covered care outside the network, often with higher cost sharing.
Before choosing or using a plan, check your doctors, specialists, and preferred hospitals. Because provider networks can change, confirm a provider's participation when reviewing your coverage and before receiving care.
Understanding how your plan's provider network works can help you make a more informed Medicare decision.