Do Medicare Cost Plans Have Networks?
This article was updated on: 10/06/2018
If you’re considering enrolling in one of the Medicare Cost Plans available in your area, you may be asking, “Do Medicare Cost Plans have networks?” It’s an important question, since it may affect the amount you pay out-of-pocket for your healthcare under one of these plans. Here’s what you should know about Medicare Cost Plans and provider networks.
What is a Medicare provider network?
Medicare Cost Plans, like Medicare Advantage Plans, are offered by private companies contracted with Medicare to provide health insurance benefits to their enrollees. These private companies have different ways of keeping costs low for their members, and one of the most common is through a provider network.
A provider network is basically a group of providers—primary care doctors, specialists, hospitals, pharmacies, laboratories, diagnostic imaging centers, home health providers, etc.—who have agreed to provide services to plan members for a certain cost, usually much lower than the amount charged people outside the plan. A provider within the plan’s group is called an “in-network provider,” while those not in the group are considered an “out-of-network provider.”
Two of the most common types of Medicare Cost Plans using provider networks are health maintenance organizations (HMOs) and preferred provider organizations (PPOs*). In an HMO, plan members must get all of their care (except for emergency care) from network providers; otherwise, they may have to pay the full cost for those services.
With a PPO, members have the option to see any provider they choose, but they pay significantly less out-of-pocket if they use providers within the plan’s network.
If you currently use certain doctors and want to stay with them, it’s important to see the provider network for any plans you’re considering before you decide to enroll. If your doctor isn’t in the network, your visits may not be covered at all, or you may pay a lot more out-of-pocket for your care.
Do Medicare Cost Plans have networks?
Because Medicare Cost Plans are offered by private organizations, usually unions or employer groups, each plan operates differently. Some Medicare Cost Plans may have networks and some don’t. Medicare Cost Plans set their own premiums, deductibles, cost-sharing structures, rules, restrictions, and exemptions. Some choose to operate as an HMO and restrict plan members to network providers, while others may choose to operate as a PPO, giving members the option of going out of network for their care.
Medicare Cost Plans operate differently than other types of Medicare health plans. For example, you can enroll in Medicare Cost Plans even if you only have Part B—and some plans may only cover services typically covered under Part B. Plans may include Part D coverage for prescription drugs, or you may have the option of buying a separate Part D Prescription Drug Plan to complement your Medicare Cost Plan. If you enroll in a Medicare Cost Plan and decide you don’t like it, you can switch back to Original Medicare at any time. You can enroll in Medicare Cost Plans whenever they are accepting new members.
Because these plans vary so much, be sure to carefully read all the plan information before you enroll so you know how your plan operates and what services are covered.
Need more information about Medicare Cost Plans and provider networks?
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*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.
The pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.