| Tue, Oct 30, 2012 @ 09:00 AM

OEP Boot Camp: Look at Your Provider Network

Posted by Medicare Made Clear

OEP Bootcamp Medicare provider network informationThe fourth in a 6-post series designed to help you make informed Medicare choices for 2013

Many people have special relationships with their doctors. The ability to continue seeing a specific doctor may be a key factor for some when making Medicare coverage decisions.

So far in this series we’ve focused on Medicare benefits and costs. Today we’re going to delve into a different area—plan networks, how they may change and what that means for you.

Provider Choice Depends on Coverage Choice

You have two ways to get Medicare—Original Medicare or a private Medicare Advantage plan. It’s important to choose the one that gives you the provider choices that work for you. 

Original Medicare is administered by the federal government. It provides nationwide coverage. Cost sharing and benefits are the same with every doctor, hospital and pharmacy throughout the country that accepts Medicare assignment. Accepting Medicare assignment means that the provider agrees to accept the amount Medicare approves for a service as payment in full.

Medicare Advantage plans are offered by private insurance companies. Most plans have a contracted network of doctors and pharmacies. Each plan negotiates special pricing with its network and passes the savings on to its plan members. Network providers are generally from within the plan’s geographic service area. You must live in a plan’s service area to be a member. (Part D prescription drug plans usually have pharmacy networks as well. We’ll discuss drug plans in our next series post.)

You can choose to see a non-network provider or one that doesn’t accept Medicare assignment. You may pay more out-of-pocket, though, whether you have a Medicare Advantage plan or Original Medicare.

Choices With Original Medicare

You don’t have a provider network, per se, when you have Original Medicare. Your “network” includes any provider who accepts Medicare. This may be a good choice if, for example, you are a frequent traveler or split your time between homes in different parts of the country. Or you may just prefer having the freedom to choose.

You may want to double check that the providers you see, or may want to see, accept Medicare assignment. If they don’t, you are 100% responsible for the cost.

It’s a good idea to look at your out-of-pocket health care costs in general, too. For most services, you pay 20% of the cost and Medicare pays 80%. You also pay the Part B premium and may have copays for some services. In addition, there is no out-of-pocket cap with Original Medicare. A serious illness can get expensive.

Choices With Medicare Advantage

Most Medicare Advantage plans have a provider network. Medicare Advantage Private-Fee-For-Service or Medicare Savings Account plans usually do not.

If you currently have a Medicare Advantage plan, you need to understand changes that may be coming in 2013. Your plan will notify you of any differences in your coverage or costs for the upcoming year before the Open Enrollment Period begins. Call your plan customer service number on your member card if you haven’t received the information.

Network-related plan changes may include:

  • Your plan will no longer serve the area in which you live. If this happens, you need to find a new plan. You can find out which other Medicare Advantage plans serve your area using the Plan Finder at Medicare.gov. Then you can then ask your doctor and other providers which of these they participate in. Most plans also allow you to search for providers on their web sites. Or, if you choose, you can switch to Original Medicare instead.

  • Your plan’s network has changed. Your plan may add or delete doctors, hospitals and other providers from their network. You need to make sure the doctors and health care facilities you use or want to use are participating in your plan.

You’ll also want to look at your plan’s cost-sharing terms for using non-network providers. You may be responsible for the entire cost. Some plans will pay a portion.

Now What?

We’ve covered a lot of information in this series so far. We hope that you have been able to begin narrowing down your choices and get closer to a final decision.

Next time we’ll be talking about prescription drug coverage. Drug costs can take a big chunk of your health care dollar. If you currently have drug coverage, or if you are thinking of adding it to your Medicare coverage, then we hope you’ll “click in” for our next topic.

Maybe you’ve already decided what you want to do. That’s great! If your decision is to make a change, and you know which plan you want to enroll in, then there’s no need to wait. Enroll whenever you are ready to.

You have from now until December 7 to change your Medicare coverage choices, if you choose. In addition to this blog series, you can get help from these resources:

  • Medicare.gov, where you can download a copy of Medicare & You 2013, search for plans and find other helpful information

  • Private health insurance company web sites for information about 2013 Medicare Advantage (Part C) and Medicare prescription drug (Part D) plans

  • The 2013 Annual Notice of Changes mailed to you from your Medicare Part C or Part D plan, if you’re currently enrolled in one

  • A licensed health insurance agent in your community who can discuss all your plan choices with you

Be sure to report back to OEP Boot Camp for our next topic, Check Your Prescription Drug Coverage. Our goal is to help you make informed choices during the Medicare Open Enrollment Period.

For more information, contact the Medicare helpline 24 hours a day, seven days a week at 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048. If you have questions about Medicare Made Clear, call 1-877-619-5582, TTY 711, 8 a.m. – 8 p.m. local time, seven days a week.


Review Your Current Medicare Coverage: Use this easy tool to help you decide whether you want to change you coverage.

Medicare.gov: Visit the official U.S. government site for Medicare.

Medicare Choices Worksheet: Download a worksheet to help match your needs to coverage choices.


Read other posts in this series:



Y0066_121016_102014 CMS Accepted