Networks are often a confusing topic for beneficiaries of any type of insurance. When it comes to Medicare, one of the more popular options is Medicare Advantage (Part C). Unlike Original Medicare (Parts A & B), the private insurers that offer Medicare Advantage plans contract with health provider networks. This can result in cost savings for plan enrollees, but it also means beneficiaries may experience a more limited pool of physicians and pharmacies within networks available in their area.

Here are five common topics around Medicare Advantage networks:

1. In-Network vs. Out-of-Network

Medicare Advantage (Part C) offers the same coverage as Original Medicare Parts A and B, but also has an associated network (either HMO or PPO). The Medicare Advantage plan provider has their network with specific doctors, facilities, and suppliers. Since plan providers 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 work well for beneficiaries looking to simplify their insurance.

2. Medicare Network Types: HMOs, PPOs, PFFS

There are three main Medicare Advantage network types: HMO, PPO, and PFFS. The main difference between these three plan types is availability and cost for non-emergency or non-urgent out-of-network coverage.

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. If you have an HMO POS (Point-of-Service) plan, you may be able to see out-of-network providers but at a higher cost. To see a specialist with an HMO plan, you may need a referral from your primary care doctor. Additionally, some HMO plans offer drug coverage.

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. 

PFFS stands for Private Fee-For-Service. These plans may or may not have networks. If you join a PFFS plan with a network, you can see any network providers who have agreed to treat you. You can also choose out-of-network providers that accept the plan’s terms — but it may cost more. If you join a PFFS without a network, you can visit any Medicare-approved provider that again accepts the plan’s terms and agrees to treat you — but not all will.

Again, the in-network vs. out-of-network coverage question is moot in emergency or urgent situations. All Medicare Advantage plan types must treat you in these situations.

3. Networks may change every year

Networks usually change every year. Doctors and physicians within the network must accept being a part of the network each year. This means that providers can choose to leave a network at any time throughout the year. According to Medicare.gov, plans “should make a good-faith effort to give you at least 30-days notice” when a provider is leaving the network to give you time to find a new provider within the network. Even with this good-faith effort, it’s important to perform your own due diligence to understand your in-network providers:

• Verify acceptance with your doctor prior to re-enrolling in your plan for another year. This can happen during Open Enrollment (Oct. 15-Dec. 7) each year.
• Check with your provider when you schedule appointments to ensure they’re still in your plan’s network.
• Understand the provider offerings in your plan’s network, to provide peace=of=mind that you’ll have options should a network change affect your first options.

4. 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. According to the Kaiser Family Foundation’s 2023 Medicare Advantage Spotlight, beneficiaries in four percent of counties in the United States can choose from three or fewer Medicare Advantage plans. The urban vs. rural discrepancy is shown most starkly in the fact that half of all Medicare beneficiaries have more than 40 Medicare Advantage plans available to them, based on where they live — but this only accounts for 19 percent of counties across the country.

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).

Key Takeaway

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 to get started.