Is Your Medicare Plan Still a Good Fit?

Posted by Aaron Pepin
Estimated Reading Time 1 minute 42 seconds

“My doctor accepts Medicare, so I should be covered.” That assumption sounds reasonable, but it can lead to unexpected expenses or difficulty scheduling care. Accepting Medicare and participating in a particular Medicare Advantage plan’s network are different things.

With Medicare’s Annual Election Period underway, understanding that distinction can help you choose coverage that supports your healthcare needs.

Original Medicare and Medicare Advantage work differently

With Original Medicare, you generally can visit any doctor or hospital that accepts Medicare. Whether a provider accepts assignment, meaning the Medicare-approved amount as full payment, can affect your costs.

Medicare Advantage plans are offered by private insurers and typically use provider networks. A doctor who accepts Original Medicare may participate in some Medicare Advantage networks while remaining outside others.

Even plans from the same insurance company can have different networks. Recognizing the insurer’s name is not enough to confirm participation in your specific plan.

Your plan type affects your options

With a Medicare Advantage HMO, you generally must use network providers, except for emergency care, out-of-area urgent care, and certain other exceptions. Routine care outside the network may not be covered.

A Medicare Advantage PPO generally offers coverage for eligible services outside its network, but your share of the cost is usually higher. Confirm coverage with the plan and whether the provider will see you before scheduling.

Ask a more specific question

Instead of asking the receptionist, “Do you take Medicare?” provide the complete plan name and identification information. Ask whether your doctor participates in that exact plan’s network for the coming coverage year.

Cross-check the answer with the insurance company. Verify the doctor’s office location, too, along with any medical group affiliation that affects access.

Include specialists, hospitals, laboratories, and other providers you regularly use in your review.

Look beyond the provider list

Keeping your doctor matters, but network participation is only one part of a good fit. Compare prescription coverage, specialist copays, referral requirements, prior authorization rules, and the plan’s annual out-of-pocket maximum.

A plan that includes your physician could still create problems if your medications become expensive or your preferred hospital is outside its network.

Review your choices during AEP

Medicare’s Annual Election Period runs October 15 through December 7, with changes generally effective January 1.

We can help you check provider participation, compare costs and coverage, and evaluate whether your current plan or another available option better fits your situation.