Licensed Insurance Agents: 888-323-1149 TTY: 711
Mon - Fri, 8am - 8pm ET

Doctors and Medicare Advantage

October 6, 2016

Doctors and Medicare Advantage

It’s good if you’re wondering ‘Does my doctor accept my Medicare Advantage plan?’ Making sure that the health-care providers whom you frequent accept your Medicare Advantage plan is an important way to keep your medical out-of-pocket costs down. The type of Medicare Advantage plan, whether it’s a Health Maintenance Organization (HMO) plan or a Preferred Provider Organization (PPO) plan, may determine if and how your doctor accepts Medicare Advantage.

Medicare Advantage Coverage

In non-emergency and non-urgent situations, it is important that you go to a doctor (or health-care facility or other health-care service provider) that belongs to your plan or accepts your plan even if the plan does not have a provider network. Depending on the particular Medicare Advantage plan you have (but especially with HMO plans), going to a health-care provider that does not belong to your plan could mean that your services are not covered and, consequently, increase your out-of-pocket costs. Additionally, certain plans may require you to get a referral to see a specialist in order to avoid higher costs. Always check with your plan before seeing a new health-care provider.

Types of Medicare Advantage Plans

  • Health Maintenance Organization (HMO) Plans: Members of HMO plans usually choose a primary care physician within a network of providers, who will refer you to specialists as needed.
  • Preferred Provider Organization (PPO*) Plans: Members of a PPO plan usually do not have to choose a primary care physician (PCP) and can see out-of-network care providers but usually at a higher out-of-pocket cost than when they see in-network providers.
  • Private Fee-For-Service (PFFS) Plans: A Private Fee-For-Service plan generally doesn’t require a primary physician and/or a network of doctors. You can usually use any Medicare-approved doctor, but payment terms for each service can change between visits.
  • Special Needs Plans (SNPs): A Medicare Advantage plan that is exclusively designed for the unique needs associated with one of the following categories: A type of chronic or disabling health condition covered by SNPs(e.g. diabetes), enrollment in both Medicaid and Medicare simultaneously, and residence in certain institutions such as a nursing home.

Doctors Accepting Medicare Assignment

Does your doctor accept Medicare assignment for medical services and procedures? He/she doesn’t have to. Doctors have three options when it comes to Medicare assignment:

  • Participating: If a doctor is participating in Medicare assignment, he or she has agreed to accept the Medicare-allowed amount as full payment for the services rendered. Normal Medicare deductibles and/or co-payments still apply for the Medicare beneficiary.
  • Non-participating: A non-participating doctor can either choose to accept the Medicare assignment amount for a service or not. If your doctor doesn’t accept the Medicare assignment amount, he or she can charge no more than 15% above the Medicare-approved fee for the service and the Medicare beneficiary is responsible to pay the extra amount along with any deductible or co-payment already required by Medicare.
  • Opt Out: These doctors have chosen not to provide services to anyone through Medicare and can charge self-determined costs for services. They are not allowed to bill Medicare for any services, and if you see a doctor who has opted out of Medicare, you will likely need to pay the entire bill.

Additional Medicare Advantage Coverage

While Original Medicare (Part A and Part B) does not cover routine vision, hearing, or dental, you may ask your Medicare Advantage plan if it covers any of these services. There are many Medicare Advantage plans across the nation that may offer additional coverage (Medicare Advantage is an alternative way to receive your Original Medicare benefits, except for hospice care, which is still covered by Part A). Please note that you’ll still need to pay your Medicare Part B premium, along with any premium the Medicare Advantage plan requires, along with any copayments, coinsurance, and deductibles.

*Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.