6 Things to Know about Medicare Networks

October 6, 2021

Networks are often a confusing topic for beneficiaries of any type of insurance. Here are answers to six of the most common questions we receive about networks.

1. What is an HMO?

HMO stands for Health Maintenance Organization. This network type is limited. If you visit a doctor, health care provider, or hospital outside of the HMO network, you will likely pay full cost for your services. To see a specialist with an HMO plan, you may need a referral from your primary care doctor.

2. What is a PPO?

PPO stands for Preferred Provider Organization. Unlike an HMO, you can get your health care services performed by anyone in or outside of their network. However, you will pay a higher amount for services from out-of-network providers. With a PPO, you do not need to have a referral from your primary care doctor to see specialists.

3. What is a Medicare network?

Medicare Advantage (Part C) offers the same coverage as Original Medicare Parts A and B, but also has an associated network (most commonly an HMO or PPO). The Medicare Advantage plan carrier has their network with specific doctors, facilities, and suppliers. Since plan carriers determine their own rules and costs, if you see an out-of-network provider, you could pay up to the full-cost for the service. Medicare Advantage plans typically bundle other kinds of coverage along with your Original Medicare coverage, so they may work well for beneficiaries looking to simplify their insurance.

4. Do networks change or stay the same each year?

Networks usually change every year. Doctors and physicians within the network must accept being a part of the network each year. When you have a network-based plan, such as Medicare Advantage, we recommend verifying acceptance with your doctor prior to re-enrolling for another year.

5. Do Medicare Supplement Plans (Medigap) have networks?

No. Medicare Supplement Insurance is highly regulated by the government, so even though they are offered by private insurance companies, these plans are guaranteed to be accepted by any health care provider who accepts Medicare (Part A and Part B).

6. How do networks differ between urban and rural areas?

Rural areas often have smaller, more limited networks. A general rule of thumb is that networks centered around areas of greater population will have more robust provider options. Network strength is often a key factor when comparing Medicare Advantage plan options.

Understanding Medicare networks is crucial, as networks can affect your ability to easily visit your doctors and physicians, but there are also many other factors to consider. Determining the best fit for your health care needs and budget can be an overwhelming task. If you’re unsure or need answers to your questions, our licensed agents are here to help you! Visit our plan comparison tool or call us at (888) 411-7647 TTY: 711 to get started.

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