Medicare Advantage Provider Networks


For most people accustomed to group or personal plans in the “under age 65” market, dealing with provider networks is an ongoing concern.  PPO or POS or HMO?  This concern is no different for those shopping for a Medicare Advantage plan.  These plans are “network driven”.

For people who do not want to worry about provider network restrictions (and don’t mind paying more premium dollars), then a Medicare Supplement (Medigap) plan is the preferable choice.  Medicare Supplement plans allow policyholders to visit any doctor that accepts Medicare.  It’s not important to ask if a doctor accepts a particular carrier, such as Blue Cross Blue Shield or Aetna –  just Medicare.

Not all providers work with Medicare policyholders — even Medigap.  They don’t accept what is called Medicare Assignment.

According to the official Medicare website:

Assignment means that your doctor, provider, or supplier agrees (or is required by law) to accept the Medicare-approved amount as full payment for covered services.

Make sure your doctor, provider, or supplier accepts assignment

Most doctors, providers, and suppliers accept assignment, but you should always check to make sure. Participating providers have signed an agreement to accept assignment for all Medicare-covered services.

So, why wouldn’t a doctor accept Medicare Assignment?  Well, they get paid less…on average, the payment is 20% less than what a private insurance plan will pay. Most doctors will continue to see their existing patients who become Medicare eligible. However, we occasionally hear about doctors who refuse to accept assignment, even for their long-term patients.  Not the best practice, in our opinion.

How Much do Medicare Advantage Provider Networks Vary?

For an in-depth look at a recent article and report by the Kaiser Family Foundation on Medicare Advantage networks, click here.   For those who would rather not read the 41 page report, I will share some of the most important points.  Below is a very helpful graphic. This study only covers 20 counties in various states (not including my home sate of Georgia), but holds true for most counties across the U.S.

Figure ES 1: Hospital Networks Vary Across Medicare Advantage Plans: 16% Have Narrow Networks and 23% Have Broad Networks

Medicare Advantage networks can vary considerably by county.

Some carriers may have strong PPO provider networks in certain counties, but in other (often times, less profitable) counties, they only offer fairly small HMO networks.  For example, Aetna has a very strong national PPO network, including Fulton county, DeKalb county, and Gwinnett county.  However, they don’t offer this same PPO network plan in Cobb or Cherokee counties.

It is important to check to see if all of your preferred doctors and providers are in-network when shopping for a Medicare Advantage plan.  Of course, provider networks are only one consideration; there are many other important factors to consider when shopping for plans.

Don’t just look at the “main” hospital(s) when making a decision.  It’s important to check to see if the Medicare Advantage plan’s network includes hospitals that include heart or cancer centers.

The study found the following:

  • Two in five plans in areas with an NCI-designated cancer center did not include the center in their networks.
  • Most plans (80%) included an Academic Medical Center in their network, but one in five did not.

The Cost of Medicare Advantage Plans and Provider Networks

Most counties have at least a couple of zero-premium Medicare Advantage plans.  Usually, the zero premium plans are HMOs – the plans with the most restrictive (smallest networks).  However, there can be very strong zero or low premium PPO plans in your county.

One surprising finding of the Kaiser Family Foundation study is the fact that there isn’t a clear correlation between HMO network size and cost:

Among HMOs, which comprised the majority of the plans in the study (75%), broad and narrow network plans had similar average premiums ($37 vs. $36 per month) and similar quality ratings (3.8 vs. 4.1 stars).

Tip: It is very important to speak with an agent that represents both Medicare Supplement plans and Medicare Advantage plans.  There can be an inherent bias if an agent only works with one type of plan.

Yes, cost is important, but there are some very good Medicare Advantage plans with premiums upwards of $30 per month.  Keep in mind, most Medicare Advantage plans include the costs of drugs.

HMO plans, although very inexpensive, limit policyholders to their network only – except in the case of emergencies.  For someone diagnosed with a serious illness, it may be difficult to hear that the best doctors or hospitals are not in-network providers.  So, it helps to consider the cost of not finding the best care and treatment available.

Check all the Medicare Advantage plans available in your county

Checking all the available plans is important.  Talking to an agent that represents all the best carriers and plans in your county is critical. For an analysis of your situation and a customized proposal, showing the most comprehensive comparison quote (for Medicare Advantage plans or Medigap plans, or both), please call us.  Whether you live in Cobb county, Georgia or anywhere in Georgia or across the nation, we’ll be glad to help.