How Can I Find a Doctor That Takes My Medicare Advantage Plan?

Steven Mott by Steven Mott | Licensed since 2012
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This article was updated on: 09/15/2018

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If you’ve chosen to get your Original Medicare (Part A and Part B) benefits through a Medicare Advantage plan, you may want to find a doctor who accepts your Medicare Advantage plan. To get the most of your plan benefits and to keep your costs low, you might need to get your health care from a doctor who participates in your plan’s network. Here’s what you need to know.

Why do I have to use a doctor who accepts my Medicare Advantage plan?

Medicare Advantage plans are offered by private insurance companies contracted with the Medicare program to provide benefits covered by Part A and Part B (except for hospice care, which is covered under Part A). These private companies look for ways to control health care expenses to help keep costs low for their members.

One of the ways plans might manage costs is by negotiating with physicians, hospitals, and other health-care providers to accept a lower rate of payment for their services than they would normally charge in exchange for access to the plan’s large group of covered members. If your plan has a provider network, you may want to see doctors who accept your Medicare Advantage plan to avoid paying more for out-of-network providers.

Medicare Advantage plans often use different incentives to encourage you to get care from network providers. Your plan may charge you a lower copayment or coinsurance amount when you use health-care providers who participate in your plan; for example, you may pay a 20% coinsurance amount for in-network providers, but 50% for out-of-network care.

In addition, a doctor who accepts your Medicare Advantage plan must accept your copayment or coinsurance amount as payment in full for your share of your health-care expenses. A non-network provider can charge you whatever their usual rate may be.

How do I know if I have to use a doctor who accepts my Medicare Advantage plan?

This depends on the type of Medicare Advantage plan you choose. Some of the most common types of Medicare Advantage plans are:

  • Health Maintenance Organizations (HMOs). Most HMOs require you to get your health care from providers in the plan’s network. You’ll choose a primary care provider (PCP) who will handle all your routine health care and refer you to specialists as needed to treat you. HMO provider networks include doctors and specialists, hospitals, surgical centers, lab and x-ray facilities, and even pharmacies if your plan covers prescription drugs. You must get all care, except emergency treatment, from doctors who accept your Medicare Advantage HMO, or your plan may not pay any of your expenses.
  • Preferred Provider Organizations (PPOs)*. PPOs let you see any provider or doctor who accepts your Medicare Advantage plan, but you pay a lot less when you use providers in the plan’s preferred provider network. Like HMOs, your plan network will include specialists, hospitals, and other providers you need for your health care needs.
  • Private Fee-for-Service Plans (PFFS). Some PFFS plans have no provider networks, and may let you see any provider who accepts the terms of your plan. Keep in mind, however, that doctors are not required to accept your PFFS plan, even if they participate in the Medicare program. Fees are set by the insurance company and a provider may choose whether or not he will treat you under your plan. Be sure to ask each time you make a health-care appointment, even if you’ve seen that provider in the past. Also, be aware that some PFFS plans do have provider networks.
  • Special Needs Plans (SNPs). SNPs function similarly to HMOs except that enrollment is limited to certain individuals who a) have any of certain qualifying chronic illnesses or conditions, b) live in a nursing home, or c) are eligible for both Medicare and Medicaid benefits.

Your plan membership information will tell you what type of plan you are enrolled in and whether or not you must use certain providers or networks.

Do I need to use a doctor who accepts my Medicare Advantage for routine vision, hearing, dental, or prescription drugs?

Medicare Advantage plans are only required to cover the same services as Part A and Part B, which do not include benefits for routine vision, dental, hearing, and prescription drugs. However, many Medicare Advantage plans do offer additional coverage for these services. If your plan has Medicare Part D coverage for prescription drugs or benefits for routine vision, dental, or hearing care, you may be required to use network providers for these services, as well. Consult your plan membership information for details.

How do I know if a doctor accepts my Medicare Advantage plan?

Most Medicare Advantage plans offer easy-to-use online tools to help you find a doctor who accepts your Medicare Advantage plan. In addition, you can call the customer service number on your plan ID card to get help finding a provider in your area. If you are enrolled in a PFFS or other Medicare Advantage plan without a provider network, it’s always a good idea to ask if your plan is accepted at the time you make an appointment or seek medical care.

If you have questions about Medicare Advantage plans in your area, I’m happy to help. To schedule a phone call or request information via email, click one of the links below. You can see a list of plans in your area by clicking the “Compare Plans” button on this page.

*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.

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