The chart below shows you how different types of Medicare Advantage Plans (private health plans) may manage your access to health care providers.
Each type of plan has different network rules. A network is a group of doctors, hospitals and medical facilities that contract with a plan to provide services. With all plan types, you will pay less if you see doctors and use medical facilities that are in your plan’s network.
Not all Medicare Advantage Plans—even plans of the same type—work the same way. For example, while HMOs provide no coverage if you go out of network (except in emergencies,) other types of Medicare Advantage Plans do cover some portion of your costs if you see out-of-network doctors. Before you join a Medicare private health plan, make sure you understand that specific plan’s network rules.
Medicare private health plans:
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 option (POS) that allows you to use non-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 (SNP) or Medicare Medical Savings Account (MSA) plans. In a MSA plan, you can go to any doctor or hospital willing to accept the plan’s fees. A SNP is managed care plan (HMO) that serves people with special needs. If you are considering joining a SNP or an MSA, ask about that specific plan’s network rules.