What to do if your preferred doctor isn’t in your Medicare plan’s network

After building a relationship with a doctor who understands your medical needs and health history, you may not want to start all over with a new physician.

Medicare Benefits Solutions

Sep 8, 2021

 5 minutes read

If your Medicare Advantage (MA) plan’s network doesn’t include your preferred doctor, or if your doctor suddenly leaves your plan, you may want to consider making a change.

If your favorite physician is not part of your Medicare Advantage plan’s network and you visit them anyway, you may be responsible for 100% of the costs of your visit and any services provided.

Depending on your needs, these visits could cost you hundreds or thousands of dollars. You don’t have to risk your finances to see your preferred doctor. In fact, you may be able to switch to an MA plan that lets you see the doctors you want and gives you the coverage you need at a price you can afford.

You deserve to have Medicare coverage that meets your needs, including giving you access to the doctors you want to see. If your current plan doesn’t give you the flexibility you’d like, consider your options. Compare other MA plans in your area. You may find a plan that includes your preferred doctor for little to no additional cost. If you find a plan you prefer, you may be able to switch during an enrollment period.

The type of Medicare Advantage plan you choose may affect the doctors you can see

Depending on the type of MA plan you currently have, you may want to consider a range of options including:

Health Maintenance Organizations (HMOs). HMOs generally require you to visit a doctor within your plan’s network, but networks vary from plan to plan. If you currently have an HMO, you may find a similar one that includes your doctor in its network.

Preferred Provider Organizations (PPOs). PPOs usually offer more flexibility and bigger networks, but may have higher out-of-pocket costs than an HMO. You may find a PPO that includes your doctor in its network, or at least allows you to visit out-of-network providers for a higher copay.

Private Fee-For-Service (PFFS) plans. Many PFFS plans will allow you to see any doctor that accepts Medicare, but some PFFS plans will have a network of providers to choose from. If a PFFS plan has a network, you may be able to see an out-of-network physician for a higher cost.

Medical Savings Account (MSA) plans. Most MSA plans will allow you to visit any doctor that accepts Medicare.

Special Needs Plans (SNPs). Many Special Needs Plans (SNPs) will have a network of providers, and you’ll have to choose a primary care physician who will coordinate your care and refer you to a specialist when deemed necessary. If the SNP is a PPO, you may be able to pay more and visit a doctor out of network.

Other factors to consider as you compare plans

Aside from getting access to your preferred doctor, other factors will contribute to your choice of Medicare Advantage plans. Consider a plan’s benefits package, including coverage for prescription drugs, vision care, routine dental care, fitness programs, and more.
MA plans can vary in costs, including monthly premiums, deductibles, coinsurance, and copays. Some plans have higher maximum out-of-pocket limits than others. If you have questions as you narrow down your choices, help is just a call or click away. A knowledgeable, licensed sales agent may be able to help you find the plan that’s right for you – and even help you switch plans when you’re ready.

Make sure you can see your preferred doctor before enrolling

When you narrow down your choices, make sure that any plan you are considering lists your physician in their network of providers. Confirm that your preferred doctor is open to accepting new patients before switching plans. (Even if you’ve previously seen a doctor, you may be considered a new patient due to the change in insurance. If your preferred provider is not accepting new patients, you may be able to ask for an exception.)

When can you switch to a plan that includes your preferred doctor in its network?

If you find a plan that gives you access to your preferred doctor – and gives you the benefits you need at a price you can afford – you may be able to switch plans during one of the following enrollment periods:

 

  • Annual Election Period (AEP), October 15 – December 7. During AEP, you can switch from one MA plan to another, drop Original Medicare and enroll in a Medicare Advantage plan, switch PDPs (Prescription Drug Plans), or even drop your MA plan and revert to Original Medicare (and enroll in a PDP at that time).
  • Medicare Advantage Open Enrollment Period (MA-OEP), January 1 – March 31. During the MA-OEP, you may make one change to your coverage. For instance, you may switch from your current MA plan to one that includes your doctor in the plan’s network.
  • Special Enrollment Periods. You may be eligible to switch Medicare plans outside of a regular enrollment period if certain events occur in your life. For instance, if you move out of your plan’s service area, move into a nursing home, or qualify for Medicaid, you may be eligible for a Special Enrollment Period.

Ready to enroll?

If your preferred doctor is not included in your Medicare Advantage plan’s network, you may consider other plans in your area that will give you access to the physicians you want to see and the coverage you need. As you explore your options, a licensed sales agent may be able to help answer questions you have – or even help you enroll when you’re ready.

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