Each type of Medicare Advantage Plan has different network rules. A network is a group of doctors, hospitals, and medical facilities that contract with a plan to provide services. There are various ways a plan may manage your access to specialists or out-of-network providers. Remember that your costs are typically lowest when you use in-network providers and facilities, regardless of your plan.
It’s important to know that not all Medicare Advantage Plans—even plans of the same type—work the same way. Make sure you understand a plan’s network and coverage rules before enrolling. If you have questions, contact your plan for more information.
General overview of provider access rules
|Do I need to get a referral before I can see an in-network specialist?||Yes, usually||No||Yes|
|Can I go to a doctor or hospital that is not in the plan’s network?||No, unless you need urgent or emergency care of if you have a Point of Service (POS) option that allows you to use out-of-network providers||Yes, but you will pay more unless it is an emergency||Yes, but you will usually pay more and the provider must agree to treat you, unless it is an emergency|
Note: This chart does not include Special Needs Plans (SNPs) or Medicare Medical Savings Account (MSA) plans. A SNP is managed care plan that serves people with special needs. In an MSA plan, you can go to any doctor or hospital willing to accept the plan’s fees. If you are considering joining a SNP or an MSA, ask about that specific plan’s network rules.