Did you know that not all doctors, hospitals, and other healthcare professionals take part in Medicare? This is an important aspect to consider when applying for Medicare coverage – individuals should check with their healthcare providers to see if they accept Medicare before seeking treatment or services. This is where understanding what a Medicare provider network is and how it works.
Why Healthcare Professionals May Not Take Part in Medicare
Some providers may choose not to partake in Medicare for various reasons. It’s advisable to verify coverage and potential out-of-pocket costs before receiving medical care.
Low Imbursement Rates
Medicare reimbursement rates are often lower than those from private insurance companies. It can be difficult for healthcare professionals to provide quality services while covering their expenses.
Administrative Burdens
Healthcare professionals who participate in Medicare must adhere to a complex set of rules and regulations, which can be time-consuming and difficult to navigate. This can detract from the time they can spend with their patients.
Care Limitations
Another reason why healthcare professionals may not participate in Medicare is because of the limitations it imposes on the types of services they can offer. Medicare may not cover certain procedures or services they feel are necessary for the patient’s well-being.
Finding a Medicare Provider Network
A Medicare provider network refers to a group of healthcare providers such as doctors, hospitals, clinics, pharmacies, and other medical facilities that have contracted with Medicare to provide services to Medicare beneficiaries. These providers have agreed and accepted Medicare’s approved rates for services, and patients who are enrolled in Medicare can visit these providers to receive covered medical care. Ultimately, this network helps ensure that Medicare beneficiaries have access to a wide range of medical services and providers.
Most Medicare Advantage plans have tailored networks and will also cover out-of-network care for emergencies/urgent care. Original Medicare does not have a network, but your doctor or other healthcare provider may still accept Medicare.
Different Medicare Network Options
Whether you’re purchasing a Medicare Advantage plan through your employer or the health insurance marketplace, you’ll have to choose between the Health Maintenance Organization (HMO) plan or the Preferred Provider Organization plan (PPO).
HMO Plan
The HMO plan allows beneficiaries to choose a primary care physician who will coordinate all of their healthcare needs from a network of doctors and hospitals that have contracted with the insurance provider. Referrals from the physician are usually required to see specialists, and out-of-network care may not be covered except in the case of emergencies. These plans typically offer lower out-of-pocket costs and may include additional benefits such as prescription drug coverage or wellness programs.
PPO Plan
This plan allows beneficiaries to see any provider they choose, but typically at a lower cost if they use healthcare providers within the network. Referrals aren’t needed to see specialists so it offers more flexibility compared to the HMO plan, but there may be higher out-of-pocket costs. Beneficiaries may also have more access to additional benefits such as preventive care services, prescription drug coverage, wellness programs, etc.
How to Find a Doctor Who Participates in Medicare
Finding a doctor who participates in Medicare is a very straightforward process. Some things you can do are:
- Check the Medicare.gov website and use the “Physician Compare” feature to find a healthcare provider in your area that accepts Medicare. You can easily search by location, specialty, etc.
- If you have a Medicare Advantage plan, you can contact your insurance provider and ask for a list of doctors who participate in Medicare in their network.
- Call your doctor’s office and ask them directly if they participate in Medicare, or, call a doctor you’ve found through your plan’s network and ask if they are accepting new patients so you can switch to their care.
- It can also be helpful to schedule an initial consultation and meet the doctor who will be providing your care. Ensure they meet your specific needs and determine if they’re a good fit for you.
Every Plan Has Its Own Set of Guidelines
When you are speaking to your doctor or are switching to a new doctor, it’s important to ask about their own set of guidelines and requirements for coverage and reimbursement. These guidelines vary based on the type of provider and the services they offer. It’s crucial for beneficiaries to understand the specific guidelines of their provider to ensure that they receive the appropriate coverage and care.
Navigate the Medicare World With the Help of a Professional
There’s no doubt about it: the Medicare world is confusing and complex. That’s why individuals should seek help from a Medicare agent who has the skills and experience necessary to connect them with the right plan for them, walk them through the application process, ensure everything is correct and submitted on time, and that they will receive the coverage they truly need and deserve. They will walk you through how Medicare Advantage works, including the advantages and disadvantages of each network option.
Emily Trevino, Senior Managing Partner at Wise Insurance, leverages her extensive background in biology and business finance to master Medicare, health insurance, and retirement planning. With over a decade in the field, Emily has co-authored “Medicare Breakdown – The Alphabet Soup of Medicare,” marking her as a pivotal figure in insurance education. Her commitment extends through active participation in the National Association of Benefits and Insurance Professionals (NABIP) and speaking at major industry events. Emily’s drive for community service and personal resilience shines through her adventurous pursuits and dedication to societal well-being. Connect with Emily on LinkedIn to explore the future of informed insurance decisions.