Medicare Networks: Who You Can See and Where You Can Go

When you enroll in Medicare, one of the most critical decisions you make is choosing how you want to access your doctors and hospitals. The path you choose determines your network - the group of healthcare providers you are allowed to see without paying massive out-of-pocket penalties.

There are two paths, not two products. You can either stay on the Traditional Medicare path (Original Medicare A and B, usually paired with a Medigap policy and a Part D drug plan) or you can choose the Medicare Advantage path (Part C). Your network rules are entirely dependent on which of these two paths you take.

If you choose Traditional Medicare, your network is simple: it is the entire United States. You can see any doctor, specialist, or hospital that accepts Medicare, anywhere in the country. There are no referrals required to see a specialist, and you don't have to worry about a doctor dropping out of a specific insurance company's network mid-year. If they take Medicare, they take your coverage. If you add a Medigap policy to fill the gaps, that policy follows you wherever Original Medicare is accepted.

If you choose the Medicare Advantage path, you are opting into a private insurance company's managed care network. These networks typically come in two forms: Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs).

With an HMO, you are generally required to use only the doctors and hospitals within the plan's local network, except in strict emergencies. If you go out of network, you will likely pay the full cost of your care. Furthermore, HMOs usually require you to get a referral from your primary care physician before you can see a specialist.

With a PPO, you have a bit more flexibility. You can see doctors outside of the plan's network, but you will pay significantly higher copays and coinsurance to do so. While you don't typically need a referral to see a specialist in a PPO, the financial penalty for leaving the network can be steep.

The paper promises of a zero-dollar premium plan look great until you need a specific specialist who happens to be out of network. We believe in straight answers, no surprises. When you are dealing with a serious health issue, the last thing you want is an insurance company telling you which doctor you are allowed to see.

Network restrictions don't just apply to doctors; they apply to hospitals and specialized treatment centers as well. If you travel frequently or split your time between two states, a local Medicare Advantage network might not cover you when you are away from home, except for emergency room visits.

Before you make a decision, you need to verify that your current doctors, specialists, and preferred hospitals are in-network for any plan you consider. But remember, networks can and do change every year. A doctor who is in-network today might not be next year.

You've worked hard for your healthcare, and you deserve to know exactly how your coverage works before you need it. We are licensed in all 50 states and are on your side of the table. We will walk you through every option and help you compare free, no obligation. Protect what you've earned by making an informed choice about your Medicare network.