Most Medicare Advantage plans have a network of doctors, hospitals, and other providers. In a Health Maintenance Organization (HMO), you generally must use network providers or the plan may not pay, except for emergency care, urgent care when you're out of the plan's area, and temporary out-of-area dialysis; in a Preferred Provider Organization (PPO), you can usually go out of network but often pay more. If you get an out-of-network bill, check whether it was an emergency, whether a plan provider sent you, and whether the plan processed the claim correctly.
How do Medicare Advantage networks work?
Medicare's booklet "Understanding Your Medicare Advantage Plan's Provider Network" describes the main plan types:
- HMO (Health Maintenance Organization): You generally must get care from providers in the plan's network. Emergency care, out-of-area urgent care, and temporary out-of-area dialysis are covered in or out of network. You may need a referral from your primary care doctor to see a specialist. An HMO with a point-of-service option may let you go out of network for some services, usually at a higher cost.
- PPO (Preferred Provider Organization): You can usually see any doctor or hospital in the network, and you can go out of network, generally at a higher cost.
- PFFS (Private Fee-for-Service): You can go to any Medicare-approved provider that accepts the plan's payment terms and agrees to treat you. Not all providers will.
- Special Needs Plans (SNPs): Some require you to use network providers; others offer out-of-network coverage at a higher cost.
Your plan's Evidence of Coverage explains its exact rules.
Why did I get an out-of-network bill?
Common reasons include:
- You saw a provider who isn't in your plan's network, without realizing it.
- A provider left the network. Plans can change networks during the year.
- A provider at an in-network hospital wasn't in network. For example, an anesthesiologist or radiologist.
- You were out of the service area for non-emergency care.
- The plan made a mistake and processed an in-network claim as out of network.
When does my plan have to pay out of network?
According to Medicare's network booklet, emergency care, urgent care when you're outside the plan's service area, and temporary out-of-area dialysis are covered whether you get them in or out of network. Medicare.gov also says that in a medical emergency, doctors and hospitals must treat you.
Another protection is "plan directed care." Medicare.gov explains that if a plan provider refers you for a covered service, or to a provider outside the network, without getting an organization determination in advance, that's plan directed care. In that situation you generally should pay only the plan's normal cost sharing.
What if my doctor leaves the network?
The booklet says:
- Your plan can add or remove providers from its network at any time during the year.
- Providers can also leave the network at any time.
- Even so, the plan must protect you from interruptions in medical care and make sure you can get medically necessary covered benefits.
- Your plan should make a good faith effort to give you at least 30 days' notice when a provider you see regularly, like your primary care doctor, is leaving.
If your doctor leaves, call your plan. Ask for help finding a new in-network provider, and ask whether you can finish a current course of treatment. A State Health Insurance Assistance Program (SHIP) counselor can tell you if you have any options to change plans.