Why I should know my network if I change Medicare plans

Always check a plan’s network to make sure your providers are included. You’ll pay less for care and medicines.

I got my hair cut last week from the same stylist I’ve had for five years, and it’s a great feeling to know and trust her all these years. My husband feels the same way about our mechanic. And the whole family is loyal to our great doctors.

If you have a favorite doctor, it’s important to check that they are in your Medicare plan’s network before you get care.

Why is it important to use in-network providers?

A network is all the doctors, clinics, hospitals and/or pharmacies that have a contract with a health plan.  You pay the least amount for health care when you use in-network providers.

Most Medicare plans have out-of-network benefits, too, but you’ll generally pay more for those services or medicines. Some plans may not have coverage at all if you go out of network for care.

Many Medicare plans also have a limit on how much you pay for covered medical services each year. It’s called the maximum out-of-pocket amount. Plans usually have a higher maximum out-of-pocket amount for care you get out of the network.

What kind of networks do Medicare plans have?

There are different kinds of networks. Some have a lot of providers, and some have a smaller number. Here’s a brief description of the networks for different types of Medicare plans.

  • Open access networks have a large number of providers. You can usually see any provider in the network without a referral. Medicare Cost plans generally have an open access network.
  • Health maintenance organizations (HMO) are smaller networks with a select group of providers. You generally must get your care and services from providers in the network. Some plans may allow you to go out of network for certain services; this is called an HMO with a point-of-service (POS) option.  Medicare Advantage plans may have an HMO or HMO POS network.
  • Preferred provider organizations (PPO) are smaller networks with a select group of providers. All plan services are covered in and out of the network; however, generally you will pay more to use out-of-network providers. This type of network could require a referral to see a specialist. Medicare Advantage plans may have a PPO network.
  • No network means you can see any U.S. provider that accepts Medicare. This is common for Medicare Supplement plans.
  • Prescription drug networks are large and include national pharmacies. Generally, your plan only covers prescriptions filled at a network pharmacy. Their network may include specialty or mail order pharmacies. Medicare Part D plans have this type of network.

Some things to consider when shopping for a plan

Keeping your doctor or switching to a new one is a personal choice. Consider these points to help guide your decision.

You may want to keep your doctor and find a plan that has your doctor in its network if you:

  • have ongoing or specialized care needs
  • have a long-term relationship with your primary care physician
  • like a surgeon who you used in the past and who you may need for upcoming surgery

Or, you may want to select a plan based on the quality of service you’ve received in the past. In that case, you may choose a plan offered by the same insurance company and decide to find a new doctor in that plan’s network

Always check that your doctor or pharmacy is in-network

Making sure you’re getting your care or your medicines in-network will help keep your costs lower. Here’s how to know if you’re in network:

  • Use the medicare.gov website to look up if a doctor, clinic, hospital or pharmacy is in your plan’s network.
  • Check with the health plan. Go to their website and use an online search tool to find a provider in the network, or call their customer service.
  • If you’re already a member, call your health plan’s member services, or log in to your personal account to search for in-network providers.
  • When you make an appointment, ask your provider if they are in your health plan’s network.