Know the Facts: Medicare Advantage and How Networks Work

Provider networks: they're vitally important, yet so often misunderstood.

Unlike Original Medicare, Medicare Advantage is sold by private insurance companies. MA plans may have provider networks that determine where you can go to receive medical treatment.

In this article, we’re exploring provider networks and why Medicare Advantage plans use networks to provide care.  

Disclaimer: Medicare Allies does not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all your options.

Why do Medicare Advantage plans have networks?

Medicare Advantage plans have networks for the same reason any other insurance plan has networks: to help regulate and predict costs.

Insurance companies work with doctors to establish set prices for different services, often at a discounted rate, for those with a particular insurance plan. In exchange, that insurance company provides more patients to doctors, because those patients are seeking out an in-network provider.

When you stay within the networks your insurance company creates, your visit costs the insurance the agreed upon, typically discounted, amount.

If you choose to visit an out-of-network provider, the insurance company has not established a set price and may charge whatever they choose. Because of this, many insurance providers will not cover, or only partially cover, out-of-network costs unless there was a life-threatening emergency that required immediate medical attention.

Do all Medicare Advantage plans have networks?

Not all Medicare Advantage plans have networks.

However, almost all Medicare Advantage plans have some form of network except for Medicare Medical Savings Account (MSA) plans.  

Provider networks can also vary between plans and carriers. Some plans, such as PPOs, offer lower rates to see in-network providers, but you can choose to see out-of-network providers.

It is always important to review plan information to see what network constraints may be present when reviewing potential plan options.  

The types of Medicare Advantage plans  

Networks can vary depending on the type of Medicare Advantage plan you choose.

The most common Medicare Advantage plan types are HMOs and PPOs, but there are a couple more, including PFFS and SNP. Let's quickly go over how networks are different for each of these plan types.

Health Maintenance Organization (HMO) Plans  

Health Maintenance Organization (HMO) plans are the strictest Medicare Advantage plan in terms of network requirements. Generally, in HMO plans, you’re required to receive care and services from an in-network provider.

They do not typically cover out-of-network costs unless the care was emergency care, an out-of-area urgent case or out-of-area dialysis.  

Some plans may offer limited out-of-network coverage, but it will cost less to go to an in-network provider. These are called an HMO with a point-of-service (POS) option.

In general, HMOs offer nice perks in exchange for these super strict networks. You may find HMOs with lots of add-on benefits, $0 premium, and other benefits that far exceed the other options in your area.

Preferred Provider Organization (PPO) Plans

Preferred Provider Organization (PPO) plans are a little less strict when it comes to requiring in-network care. While they do have networks, they don’t require you to use them like HMOs do.

Instead, in-network providers will cost you less money than those outside of their network.

PPOs are the most popular type of Medicare Advantage plan due to the flexibility, but you won't typically see as many perks or extra benefits as HMOs.

It's certainly a give-and-take, and our licensed sales agents here at Medicare Allies can help you find the plan type that matches your needs and budget.

Private Fee-for-Service (PFFS) Plans

Private Fee-for-Service (PFFS) plans are a type of plan that may have a network. If that’s the case, you can see any of the providers who are in-network. You can also choose an out-of-network health care provider, but it will usually cost more money.  

If you join a PFFS plan that doesn’t have a network, you can go to any provider that accepts Medicare. However, you will need to check before each visit that they will accept Medicare coverage because not all health care providers do.

Bear in mind that, like with the HMO, emergency services are exceptions to the rule because hospitals and other health professionals are required to treat you in emergency situations.  

Medicare Special Needs Plans (SNP)

Medicare Special Needs Plans are a special coverage for those with specific needs, such as dual eligibility with Medicaid (called a D-SNP) or those living with a chronic medical condition (called a C-SNP).

SNP plans have SNP networks for most non-emergency situations. They will also typically have extra specialists in their networks that work with specific conditions or diseases that may affect those who qualify for that plan.  

A network for everything

One of the things that you need to know about networks is that they apply to more than just your doctor. Anything your plan covers will have some kind of network coverage, from pharmacies to hospitals.  

One of the things that can also cause confusion is that, even if your hospital is in-network, your doctor or specialist you see during your stay might not be. When selecting your plan, make sure you’re reading the plan information and doing everything in your power to stay in your network.

In case of emergency

There are times when network coverage makes exceptions: emergencies. You will never be denied emergency care because of a network issue.

If you need emergency care, urgent care or out-of-network dialysis, network rules are more flexible in life-threatening situations.  

Conclusion

Networks are a major part of Medicare Advantage plans.

From determining coverage amounts to determining who you can see, your network plays a key role in your health care coverage. That’s where a licensed insurance agent can help.  

We can help you explore the Medicare Advantage plans available in your area and help you determine whether your current providers, pharmacies and hospitals will be covered on that plan.

We can also sort plans by which doctors and specialists you currently see to ensure your plan is the most compatible fit for you. Give us a call at 833-801-7999 to schedule an appointment today!