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What are Medicare Advantage Provider Networks?

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What are Medicare Advantage Provider Networks?

There are three types of Medicare Advantage plan networks. There are some minor exceptions but not enough to note here.

  • PPO – Preferred Provider Organization: You can use any doctor and hospital in or out of the plan’s network. Out-of-network providers do not have to accept you as a patient, nor is there a contractual obligation for them to bill your Medicare insurance company.
  • HMO – Health Maintenance Organization: You cannot use any doctors out of the plan’s network.
  • HMO–POS – Health Maintenance Organization–Point of Service: While rare, these plans let you go out of the plan’s network, often requiring a referral from a doctor who is in the network

All Medicare Advantage plans (except very rarely-offered PFFS, private-fee-for-service plans, and MSA plans) come with networks—HMO, HMO-POS, or PPO. Don’t assume your doctor will accept your Medicare Advantage plan even if they accepted the same brand name from your Affordable Care Act (ACA) plan or your employer-based insurance. They’re separate contracts.

In order to control their costs (a key to managed care), Medicare insurance companies contract with a network of medical providers they either force you to use (HMO) or would like you to use (PPO). That’s because the insurance company contracts with these medical providers who agree to charge certain prices in certain ways. If you stay in their networks, the prices you get charged are lower. This shouldn’t be anything new to you; provider networks have been around since the first Blue Cross and Blue Shield plans were around in the 1930s, and you’re probably very familiar with the concept if you ever had employer-sponsored health insurance or an ACA plan.

Medicare Advantage Networks and Consumer Choice

This phrase can mean many things to many people. Here, I’m using it to refer to the choice of doctors. It’s simple; if you buy a Medicare Advantage plan, you’re going to either be buying a version of an HMO or a PPO plan.

An HMO restricts your provider choices to those the insurance companies have contracted with, often in a geographic area or county. They may or may not have travel benefits if you go outside the network area. There are (usually) no out-of-network benefits. That is to say, if you go to a doctor or hospital outside of what’s listed in your provider directory, the Medicare Advantage plan does not have to cover that expense.

For many people living in one area of the country, this works out just fine. If they check and see that their doctor(s) are in the network and their preferred hospital or hospital system is as well, they’re just fine staying in the network.

For others, a PPO might make more sense.

A PPO Medicare Advantage plan has, essentially, two networks. One is considered in-network, which is to say, the insurance company has a contract with these doctors and hospitals to bill preferential rates for their services. If you get care from the doctors and hospitals in the network, you pay less out of pocket.

However, the second network is everyone else who accepts Medicare and bills the insurance company. You can still go, but the amount of money you’ll have to pay out-of-pocket can significantly increase. In other words, you have more choices, but you’ll pay more for that choice if you choose to go outside of the network.

At Chicagoland Medicare, we like PPO plans. We like having the option of going outside of the plan’s network if someone wants or need to. Would we recommend you pay a whole lot of premium to buy a PPO over an HMO? It all depends. How stark are the differences in benefits and cost? Ultimately, it’s up to you. Some people hate the HMO acronym because they remember HMOs being dragged through the nightly news in the 1980s. For others, it works very well for them due to the managed care and great benefits.

Medicare Advantage Plan Networks and Travel

If you have a Medicare Advantage PPO (Preferred Provider Organization) plan, those by design have out-of-network coverage if you’re traveling out of your service area in the U.S. Often, it’s covered, but at the out-of-network rate and will cost you more than if you would have stayed in their network. This is one of the nice features of Medicare Advantage PPO plans. The out-of-network MOOP will be higher than your in-network MOOP, so be aware of that. Many Medicare Advantage PPO plans have national networks—which means you can potentially stay in network outside of your state. This can be a big deal if you’re a snowbird or visit family outside of your home state or area for extended periods. Not all Medicare Advantage PPOs have this feature. So, again, ask your Chicagoland Medicare insurance agent about it if it’s important to you.

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Frequently Asked Questions

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How Does Chicagoland Medicare Get Paid?

Independent Medicare insurance agents and agencies such as Chicagoland Medicare get paid by the insurance companies they represent. The commissions we are paid are already built into the insurance policy you’ve purchased, and there isn’t a way to carve them out of the monthly premium. There is no extra fee for buying a Medicare insurance policy through Chicagoland Medicare, nor will you ever pay a fee for our help.

A local, independent Medicare insurance agent represents multiple carriers so that they can work to give you an unbiased opinion on your Medicare insurance plan options. Chicagoland Medicare agents and agencies are state-licensed, trained, tested and appointed by a hand-selected number of Medicare insurance companies to be able to shop and compare Medicare insurance polices to make sure we find the right fit for you! We explore your healthcare and financial needs and listen to your feelings around options available in your local area. We search for a plan that most closely fits your individual needs and budget.

Is Chicagoland Medicare free? Yes, our services are completely free to you and anything we get paid is paid to us by the Medicare insurance companies.

The monthly premiums you pay for your Medicare insurance policies are exactly the same. You cannot buy a Medicare insurance policy directly from a Medicare insurance company at a lower rate.

We have years of experience selling Medicare insurance in the Chicago area including Illinois, Wisconsin and Indiana.

There are all sorts of differences in the amount of coverage and they type of Medicare insurance coverage you can buy depending on what state and county you live in! Chicagoland Medicare independent Medicare agents have a lot of real-world experience and insight regarding the inner-workings of Medicare insurance companies that you, the consumer, may not have access to, such as Medicare Advantage service areas, Medicare Supplemental (Medigap) annual premium increase trends, application fees, discounts programs and more.

Only independent Medicare insurance agents and agencies like Chicagoland Medicare can offer a variety of plans and an unbiased, multi-company approach so our recommendations are objective unbiased and personalized when we sell you a Medigap, Medicare Advantage or Part D drug plan that’s right for you.

At Chicagoland Medicare, we specialize in Medicare insurance products. Period. We’re not distracted by attempting to sell you life insurance, financial planning services, stocks, bonds or anything else. Medicare insurance is all we do! Unlike many other Medicare insurance agents and brokers, we don’t sell group small business health insurance polices, disability insurance, home or auto insurance. We are a boutique Medicare insurance agency, we like it that way and we’re awesome at what we do.

We only partner with ‘A’ rated, household name, established Medicare insurance companies who offer Medicare Advantage, Medicare Supplement, Medigap and Medicare Part D plans in Illinois, Indiana and Wisconsin.

We do not contract with, nor offer our clients startup, new or state-based, regional Medicare insurance companies. We believe in partnering with established companies for consistency, financial strength and experience.

Sometimes, Medicare insurance agents and agencies try to offer too many different insurance products from too many companies. There are literally thousands of combinations of Medicare insurance plan combinations to choose from in the Chicago area – we choose to focus on a select few of large, reliable, well-established, and financially sound Medicare insurance companies to partner with. Oftentimes, other local Medicare agents and agencies get pulled in too many directions with too many insurance offerings and therefore can’t be as knowledgeable as possible about any carrier or one insurance type over another.

At Chicagoland Medicare, we limit the number of Medicare insurance carriers who have access to our clients. We work hard to know the deep inner-workings of each of our Medicare insurance partners which means our agents and our clients aren’t distracted by small, startup Medicare insurance companies who may have a great product for a year or two, then fade into the background and exit the market. We know our Medicare insurance company representatives by name, and know how to navigate their systems and processes.

The bottom line: Chicagoland Medicare is an independent Medicare insurance agency. We are not owned by a Medicare insurance company or by some large, national entity. We’re your local Medicare insurance agency for the Chicago area. This means we only work with hand-selected Medicare insurance companies so that we can provide you with the best Medicare plan for you that’s individualized and personalized. We exist and work ONLY for our clients, unencumbered by having to push just one company’s Medicare insurance products.