When comparing Medicare Advantage plans, it’s easy to focus on the monthly premium, copays, prescription coverage and extra benefits.
But there’s another question that can be just as important:
Are the doctors and hospitals you want to use in the plan’s network?
A Medicare Advantage plan’s provider network can affect where you receive care, how much you pay and, depending on the type of plan, whether a non-emergency service is covered at all.
That’s why checking the provider network should be an important part of evaluating a Medicare Advantage plan.
What Is a Medicare Advantage Provider Network?
A provider network is a group of doctors, hospitals, clinics and other healthcare providers that have contracted with a Medicare Advantage plan to provide covered services to its members.
Depending on the plan, the network may include:
- Primary care doctors
- Specialists
- Hospitals
- Clinics
- Laboratories
- Imaging facilities
- Skilled nursing facilities
- Home health providers
- Other healthcare professionals and facilities
Not every doctor or hospital participates in every Medicare Advantage plan.
Two plans offered by the same insurance company can even have different provider networks.
That’s why it’s important to check the specific plan you’re considering, rather than simply asking whether a provider “takes” a particular insurance company.
Why Do Medicare Advantage Networks Matter?
Your network can affect three important things:
Access
The network helps determine which doctors, specialists, hospitals and other providers you can use under the plan’s rules.
Cost
Using an out-of-network provider may result in higher costs under plans that provide out-of-network coverage.
Coverage
With some Medicare Advantage plans, non-emergency services received outside the network generally aren’t covered except in specific circumstances.
The exact rules depend on the type of Medicare Advantage plan.
Health Maintenance Organization Networks
A Health Maintenance Organization Medicare Advantage plan generally requires you to receive covered healthcare from doctors, hospitals and other providers in the plan’s network.
There are exceptions.
For example, Medicare provides protections for emergency care, urgent care and certain out-of-area dialysis services.
Some Health Maintenance Organization plans may also offer a point-of-service benefit that allows certain services outside the network, usually at a higher cost.
Because network rules can vary, always check the specific plan before receiving non-emergency care outside its network.
Preferred Provider Organization Networks
A Preferred Provider Organization Medicare Advantage plan also has a network.
However, these plans generally provide more flexibility to receive covered services outside the network.
You typically pay less when you use providers in the plan’s network.
You can generally use an out-of-network provider for covered services, but you’ll usually pay more.
There’s another important consideration:
An out-of-network provider isn’t necessarily required to treat you simply because you have a Preferred Provider Organization plan.
Before receiving non-emergency care outside the network, it’s a good idea to confirm that the provider will see you under your plan and understand what your costs will be.
Don’t Ask Only, “Does My Doctor Take Medicare?”
This question can cause confusion.
A doctor may accept Original Medicare but not participate in your particular Medicare Advantage plan’s network.
Likewise, a clinic may contract with one Medicare Advantage plan from an insurance company but not another.
Instead, ask:
“Is this doctor in-network for this specific Medicare Advantage plan?”
Be as specific as possible.
Have the exact plan name available when checking.
Check More Than Your Primary Care Doctor
Your primary care doctor is important, but your Medicare Advantage network review shouldn’t stop there.
Consider checking:
- Your primary care doctor
- Cardiologist or other specialists
- Preferred clinic
- Preferred hospital
- Healthcare system
- Physical therapist
- Behavioral health providers
- Skilled nursing facilities you might prefer
- Other providers you regularly use
If you have an established relationship with a particular specialist or hospital system, its network status could be an important factor in your Medicare decision.
Your Doctor and Hospital May Not Be in the Same Network
Don’t assume that because your doctor participates in a plan, your preferred hospital does too.
Doctors, clinics and hospitals can have different contracts.
For example, your primary care physician could participate in a Medicare Advantage plan while another specialist or hospital you use does not.
That’s why it’s useful to think about your healthcare as a system of providers, rather than checking only one doctor’s name.
Provider Networks Can Change
Provider networks aren’t necessarily permanent.
Doctors, hospitals and other providers can enter or leave a Medicare Advantage plan’s network.
The Centers for Medicare & Medicaid Services requires Medicare Advantage organizations to maintain networks that meet applicable access standards, but individual provider participation can still change.
That means confirming that a doctor is in-network when you enroll doesn’t guarantee that the doctor will remain in the network indefinitely.
If a provider leaves the network, your plan may be required to provide notice in certain circumstances and may have continuity-of-care responsibilities depending on the situation.
Don’t Rely on an Old Provider Directory
Provider directories are useful, but network information can change.
Before enrolling in a Medicare Advantage plan, check the plan’s current provider directory.
For providers that are particularly important to you, consider taking an additional step:
Contact the provider’s office and the Medicare Advantage plan.
Give them the exact plan you’re considering and ask whether the provider participates in that specific network.
This can be particularly important when you’re checking a specialist, hospital or healthcare system that you know you want to continue using.
What If You Travel?
Network rules deserve extra attention if you travel frequently or spend part of the year outside Minnesota.
Emergency and urgently needed services have protections when you’re away from your plan’s service area.
Routine non-emergency care is different.
Whether routine care outside your local network is covered — and what you pay — depends on your particular Medicare Advantage plan and plan type.
If you’re a Minnesota resident who spends winters in Arizona, Florida, Texas or another state, for example, don’t assume you’ll have the same access to routine healthcare there that you have at home.
Review the plan’s rules before enrolling.
Networks Can Be Especially Important in Rural Minnesota
Provider access can take on additional importance in rural communities.
If there are relatively few hospitals or specialists near you, the network status of those providers can significantly affect how practical a Medicare Advantage plan is for your situation.
Before enrolling, consider questions such as:
Is my local hospital in-network?
Are the specialists I use in-network?
If I need specialized treatment, where would I need to travel?
Are the larger healthcare systems I might use included?
For someone living in northern or rural Minnesota, those questions may be just as important as the plan’s premium.
Medicare Requires Adequate Provider Networks
Medicare Advantage plans don’t have unlimited freedom to create inadequate networks.
The Centers for Medicare & Medicaid Services establishes network adequacy requirements for Medicare Advantage organizations that use provider networks.
Those requirements are designed to help ensure that beneficiaries have reasonable access to covered healthcare services.
The standards include requirements involving the number and availability of certain types of providers and facilities, along with applicable time and distance standards.
However, meeting Medicare’s network requirements doesn’t necessarily mean that your preferred doctor, specialist or hospital will be in the network.
That’s why an individual network check is still important.
Network Size Isn’t the Only Question
A plan may advertise access to a large network.
But the number of providers isn’t necessarily the most useful question for you personally.
What matters more is whether the network includes the providers you actually want or need to use.
A network containing thousands of providers may not be particularly useful if your cardiologist, oncologist or preferred hospital isn’t among them.
Instead of asking:
“How big is the network?”
Consider asking:
“Does this network work for me?”
Provider Network vs. Provider Availability
Being listed as an in-network provider doesn’t necessarily mean you’ll immediately be able to get an appointment.
A provider may:
- Not be accepting new patients
- Have a long wait for appointments
- Practice at several locations with different arrangements
- Have recently changed network participation
Network participation and appointment availability are different questions.
If a particular provider is important to you, confirm both.
Five Things to Check Before Enrolling
Before enrolling in a Medicare Advantage plan, consider doing this network review:
1. Check your primary care doctor
Confirm participation in the exact plan.
2. Check your specialists
Pay particular attention to doctors you see regularly.
3. Check your preferred hospital and healthcare system
Don’t assume they’re included because your doctor is.
4. Understand out-of-network coverage
Know what happens if you receive care outside the network.
5. Think about where you receive healthcare
Consider travel, seasonal residences and whether you regularly receive care outside your home area.
Don’t Choose a Medicare Advantage Plan Based on Network Alone
Provider networks are important, but they’re only one part of evaluating Medicare coverage.
You should also consider:
- Monthly premium
- Deductibles
- Copays
- Coinsurance
- Maximum out-of-pocket limit
- Prescription drug coverage
- Pharmacy network
- Prior authorization requirements
- Supplemental benefits
- Your individual healthcare needs
A plan with your doctors in-network may still have costs or coverage rules that don’t fit your needs.
Likewise, an attractive premium or benefit package may not be particularly useful if the providers you rely on aren’t available through the plan.
Review Your Network Every Year
Even if you’re happy with your current Medicare Advantage plan, review its network for the coming year.
Plans can change.
Providers can change.
And your healthcare needs can change.
When you receive your Annual Notice of Change in the fall, review what’s changing for the next year. Then verify the doctors, hospitals and other providers that matter to you.
An annual Medicare review doesn’t mean you need to change plans.
It simply means you’re making an informed decision about whether your current coverage still fits your needs.
The Bottom Line
A Medicare Advantage provider network isn’t just a list of doctors.
It can affect:
Where you receive care.
How much you pay.
Whether certain non-emergency out-of-network services are covered.
Before enrolling in a Medicare Advantage plan, don’t just compare premiums and extra benefits.
Check the providers that matter to you.
And don’t simply ask whether your doctor “takes Medicare.”
Ask:
“Is my doctor in-network for this specific Medicare Advantage plan?”
That one question can prevent an unpleasant surprise later.
Medicare Guidance for Minnesotans
At YourMedicareMN, our focus is education first.
We help Minnesota Medicare beneficiaries understand provider networks, healthcare costs, prescription coverage and the other details that can affect how Medicare coverage works in everyday life.
Visit Contact Us to schedule a personalized Medicare review and get answers tailored to your situation.
For official Medicare information, visit the Medicare.gov website.
YourMedicareMN is not connected with or endorsed by the U.S. government or the federal Medicare program. Plan availability and benefits vary by location and plan. Contact the plan or Medicare for complete plan information.
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Medicare Guidance for Minnesotans