All About Medicare Plan Networks

Depending on which type of policy you have that supplements your Medicare will dictate if you have a network of doctors and hospitals or not.  Some Medicare plans are either HMO or PPO networks and original Medicare is a national fee for service with no networks. There are big differences between these policies with respect to provider availability and access to the care you need to understand before a claim arises. 

Original Medicare

Original Medicare was signed into law in the 1960s at a time when health care in this country was a lot different than it is today.  There were not near as many life-saving medical advances and treatments and, as a result, expenses were much lower on an inflation-adjusted base than they are in modern times.  As a result, there was very little pressure to contain costs through network formation and negotiations between the provider and third-party insurance companies.

 To this day Original Medicare is a national fee for service with no networks anywhere across the country.  Essentially if you’re enrolled under Original Medicare, you can see any doctor or hospital anywhere in the nation willing to accept Medicare without referrals to see specialists. 

Therefore, the Medigap or Medicare Supplement Plans that go behind your original Medicare are accepted with any provider that will accept your Medicare. This feature of original Medicare does make owning one of these Medigap plans extremely valuable if you get sick and need to see an out of town provider or hospital. 

Having original Medicare is nearly a must if you travel around often or move across state lines because you will find it much easier to gain access to providers across the country under the original Medicare program versus one of the many regional and local replacement plans, known as Medicare Advantage plans.

Medicare Advantage Plans

Medicare Advantage plan access and availability were greatly expanded with the Medicare Modernization Act in 2005.  These plans work differently than original Medicare having either HMO or PPO networks of providers. These networks are sometimes national and in many cases, can be regional in scope, limiting availability to providers within a certain geographic area. 

HMO plans are the most restrictive only allowing their policyholders to see in-network providers. Out of network providers are nearly always denied accept in life-threatening emergency situations. PPO plans are less restrictive but still require policyholders to use certain providers in-network or else pay more copays for seeing out of network providers.  These higher copays can really add up to thousands of dollars out of pocket for large claims.

Check with your agent or broker regarding your plans’ network, if any.  Or, you may contact your insurance company directly or visit their website regarding their list of in-network providers.  Usually, you can search for specific providers by name or by the geographic location under your carrier’s site. Beware that these networks can change rapidly so it’s always a good idea to contact your doctor directly in order to confirm they do in fact accept your plan before you see them.

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