What to do if your MA plan doesn’t cover care in your preferred hospital

Medicare Benefits Solutions

Sep 12, 2021

You may prefer to receive care from a particular hospital because of its reputation, your experience, or its proximity to your home. But, you may be disappointed to learn that it’s not included in your Medicare Advantage (MA) plan’s network of providers. If you can’t go to your preferred hospital for care when you need it, you may want to consider your options.

If you are admitted to a hospital regularly for care, or you simply want the option of getting covered care at the hospital of your choice, you may want to consider switching to an MA plan that allows you more flexibility.

If you’re unsatisfied with your hospital options with your current Medicare Advantage plan, explore other plans available. You may find a Medicare Advantage plan that gives you access to the hospital you prefer – and gives you the benefits you need at a price you can afford.

If you need help narrowing down your choices, or you have questions along the way, a knowledgeable, licensed sales agent may be able to help you find a plan that’s right for you – and help you enroll when you’re ready.

Comparing Medicare Advantage plans

As you know, Medicare Part A helps cover services and supplies you receive once you are formally admitted into a hospital. Medicare Advantage plans include your Part A benefits, but many MA plans offer additional hospital-related benefits. The type of plan you choose can affect your coverage and costs.

Some plans, like Health Maintenance Organizations (HMOs), may require you to visit hospitals within the plan’s network, but MA plans have different networks of providers. You may find that another HMO plan in your area has similar benefits and lets you visit your preferred hospital.

Or, you may consider a different type of Medicare Advantage plan. For instance, a PPO (Preferred Provider Organization) may have a bigger network of providers to choose from than an HMO. A PPO may also allow you to visit an out-of-network hospital for a higher cost. Other types of MA plans, like PFFS (Private Fee-For-Service) or MSA (Medical Savings Account) plans, may allow you to visit any facility that accepts Medicare, but costs vary. Generally speaking, HMOs usually have lower out-of-pocket costs like premiums and copays.

If your preferred hospital isn’t included in your Medicare Advantage plan’s network, or the hospital no longer accepts your Medicare insurance, consider your options. You may find a different plan that allows you access to your preferred provider with little to no additional cost.

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Considering the big picture

As you weigh the pros and cons of other MA plans, there are a number of factors that you can consider. Aside from the plan’s network of hospitals and providers, compare benefits and overall costs. Many MA plans include additional benefits beyond Part A and Part B, such as prescription drug coverage, vision and dental care, hearing exams, and fitness programs. If you already have prescription drug coverage, you need to make sure that any medications you currently take are included in a new plan’s formulary as well.

Costs such as monthly premiums, deductibles, coinsurance and copays can affect your choice in plans as well. Plans with greater flexibility may have higher premiums and doctor copays. If you find a plan that meets your personal needs and preferences – and gives you access to your preferred hospital – you may be able to switch plans during an enrollment period.

When can you switch Medicare Advantage plans?

There are certain times of the year when you can make changes to your Medicare coverage, including:

  • Annual Election Period (AEP): October 15 through December 7, you have the opportunity to switch from one MA plan to another, or drop Original Medicare and enroll in a Medicare Advantage plan. You could also switch PDP plans, or drop your MA plan and revert to Original Medicare (and enroll in a stand-alone PDP at that time.
  • Medicare Advantage Open Enrollment Period: From January 1 through March 31, you may make one switch from your MA plan to another.
  • Special Enrollment Period (SEP): You may be able to switch plans if you experience certain life events. If you move out of your current plan’s service area, move into a nursing home, or qualify for Medicaid, you may be able to drop your MA plan and enroll in a different one.

Ready to switch plans and get Medicare coverage at your preferred hospital?

If your current plan doesn’t give you access to the hospitals and providers you prefer, consider switching to a plan that includes them in their network.

Compare your current coverage to others available in your area. You may find a plan that gives you the benefits you need and allows you to visit the hospital you prefer when it’s necessary. If you have questions along the way, don’t hesitate to reach out to a licensed sales agent who may be able to help you find a plan that meets your needs – and even enroll when you’re ready.

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