Medicare Advantage provider networks are not the same

One of the biggest factors that can affect how you use your Medicare Advantage plan and receive benefits is the plan’s network of providers. Many people make a common mistake about their plan’s provider network: They only check to see if their providers are included. But there is much more than that.

If we are going to decide which type of provider network is best, we must first agree on the definition of better in this circumstance. You certainly want all of your providers included, but for our purposes that definition (a network that includes your providers) is too shallow.

All types of networks could include their providers. What you should strive for in an Advantage Plan provider network with flexibility and freedom in how you can use your plan and receive benefits.

Types of Provider Networks: How They May Affect Use of the Plan

Plan availability varies widely and you may not have plans with all of the network types discussed.

Medicare HMO

HMOs are most popular in service areas with larger populations. An insurance company that wants to offer a Medicare Advantage Plan with a network of HMO providers must have many types of providers and facilities to establish a Health Maintenance Organization (HMO).

When you join an HMO, you must choose a primary care provider who will then refer you to any specialists you need. The plan will not pay if you try to get services out of network. For example, if you have a rare disease and find out that the recommended treatment isn’t available in-network, you’re out of luck. Unfortunately, people usually find out about this only after a diagnosis.

Medicare HMO-POS

A point-of-service network HMO is very similar to an HMO, except you can receive some services outside of the network, but only at specific locations. You have a little more freedom and flexibility, but you still may not be able to get the leading treatment that is only offered out of network.

Medicare PPO

You will still choose a primary care provider when you join a Preferred Provider Organization, but you usually won’t need a referral to see a specialist. You can shop for service outside of the network, but you’ll usually pay more for that flexibility. For example, if your PPO requires a $10 copay for an in-network primary care visit, you can pay $20 for an out-of-network visit.

The great benefit of this type of provider network is the ability to receive services outside the network, if you choose. If you find yourself in the situation detailed above, you will be able to travel and receive state-of-the-art treatment. But please note that it may have a higher price.

Yew better means more flexibility and freedom, it would seem that the Medicare PPO wins. But, like everything about Medicare Advantage plans, the provider network is an individual consideration. Network type is just one more thing to consider before signing up for a plan.