Thu. Feb 2nd, 2023

Medicare Advantage provider networks are not created equal

One of the biggest factors that can affect how you use your Medicare Advantage Plan and receive benefits is the plan’s provider network. Many people make a common mistake about their plan’s provider network: They only check to see if their providers are included. But there’s a lot more to it than that.

If we are going to decide which type of provider network is best, we must first agree on the definition of best in this circumstance. You certainly want all your providers included, but for our purposes that definition (a network that includes your providers) is too superficial.

All types of networks could include your providers. What you should strive for in an Advantage Plan provider network with flexibility and freedom in how you are able to use your plan and receive benefits.

Provider network types – how they can affect plan usage

Plan availability varies widely and you may not have plans with all the types of networks discussed.

Medicare HMO

HMO’s are more popular in service areas with higher populations. An insurance company that wishes to offer a Medicare Advantage Plan with a HMO provider network must have a lot of provider types and facilities to set up a Health maintenance Organization (HMO).

When enrolled in an HMO, you must choose a primary care provider who then refers you to any needed specialist. The plan will not pay if you attempt to receive services out-of-network. For instance, if you have a rare disease and learn that the recommended treatment is not available in-network, you will be out of luck. Unfortunately, people normally learn about this only after a diagnosis.

Medicare HMO-POS

An HMO Point of Service network is very similar to an HMO except you are able to receive some services out-of-network but only at specific locations. You have a little more freedom and flexibility but you could still find yourself unable to get the leading treatment that is only offered out-of-network.

Medicare PPO

You will still choose a primary care provider when enrolled in a Preferred Provider Organization but will generally not need to get a referral to see a specialist. You can seek service out-of-network but will normally pay more for that flexibility. For instance, if your PPO requires a $10 copay for an in-network primary care visit, you may pay $20 for an out-of-network visit.

The big benefit with this type of provider network is the ability to receive services out-of-network if you choose. If you find yourself in the situation detailed above, you would be able to travel and receive the cutting edge treatment. But, be aware that it may come with a higher price.

If best means more flexibility and freedom, it would seem that the Medicare PPO wins. But, like anything related to Medicare Advantage Plans, the provider network is an individual consideration. The type of network is just one more thing to consider before enrolling in a plan.