Medicare Networks: 6 Things to Know

Networks are often a confusing topic for beneficiaries of any type of insurance. Here are answers to six of the most common questions we receive about Medicare networks. As always, we are here to help if you have any Medicare network questions not covered below.

1. What is an HMO?

An HMO is a Health Maintenance Organization. If you visit a doctor, health care provider, or hospital outside of the HMO network, you will likely pay full cost for your services. To see a specialist with an HMO-based plan you may need a referral from your primary care doctor. Additionally, some HMO plans offer drug coverage. There are currently about 470 HMO plans throughout the United States.

2. What is a PPO?

PPO stands for Preferred Provider Organization. Unlike an HMO, you can get your health care services performed by anyone on or off their list. For health care providers not on the plan’s preferred provider list, you will likely pay more for services. 64% of those enrolled in Medicare Advantage plans are in HMOs and 31% in PPOs.

3. What is a Medicare network?

Medicare Advantage (Part C) can cover Original Medicare Parts A and B but limits you to a specific group of healthcare providers you can see (HMO or PPO networks). The Advantage plan provider has their network with specific doctors, facilities, and suppliers. Since plan providers determine their own rules and costs, if you see someone outside of the network, you could pay up to the full-cost for the service.

4. Do networks change or stay the same each year?

Networks usually change every year. Doctors and physicians within the network must accept being a part of the network each year. When you have a network-based plan such as Medicare Advantage, we recommend verifying acceptable with your doctor prior to re-enrolling for another year during AEP.

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).

6. How do 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.

Understanding Medicare networks is crucial, as networks can affect your ability to easily visit your doctors and physicians. Determining the best fit for your healthcare 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!

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