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Eliminating Medicare Advantage Plans that Don’t Cover Your Doctors

Learn how to make sure your Medicare plan covers your doctors and avoid coverage headaches

4 mins read
Our goal is to give you the tools and confidence you need to improve your health and finances. Although we may receive compensation from our partner insurance companies, whom we will always identify, all opinions are our own. CoverRight Inc. and CoverRight Insurance Services Inc. (NPN: 19724057) are collectively referred to here as "CoverRight".

“Visits to your doctor aren’t covered by your Medicare plan” is a sentence that no one likes to hear.

You might hear that bad news when you go in for an appointment with the physician in question, even if you have been there many times in the past. Or you might get that news when you are first enrolling in Medicare and are checking whether visits to your favorite care providers will be covered by the plan.

At either time, it is bad news to get. But the fact is that with a little planning you will never encounter that problem. In this article you will find out how to avoid it. In nearly all cases you can, provided you choose the right Medicare Advantage Plan.

Be Sure to Understand the Difference Between Original Medicare and Medicare Advantage Plans

Before you can avoid the problem, you need to understand the difference between Original Medicare and Medicare Advantage plans. Here are the basics.

Original Medicare and Medicare Advantage plans are two different options for individuals who are eligible for Medicare. Here are some key differences:

Original Medicare is the traditional fee-for-service program offered by the Federal government. It is made up of two parts:

  • Part A (Hospital Insurance) – This covers inpatient hospital stays, skilled nursing facility stays, hospice care, and some home health care.
  • Part B (Medical Insurance) – This covers doctor services, outpatient care, medical supplies, and some preventive services.

Medicare Advantage plans, also known as Medicare Part C, are offered by private insurance companies that contract with Medicare. These plans must provide the same coverage as Original Medicare (Parts A and B), but may also offer additional benefits, such as prescription drug coverage, vision, dental, and hearing care. Medicare Advantage plans also have a network of providers that members must use to receive care and may require prior authorization for certain services.

Medicare Advantage plans may offer additional benefits beyond Original Medicare, such as prescription drug coverage (also called Part D), vision, dental, and hearing care. Remember that original Medicare does not offer these additional benefits.

How Does Your Medicare Selection Impact Your Ability to See the Doctors You Want?

Original Medicare allows you to see any doctor or hospital that accepts Medicare, without needing a referral. Medicare Advantage plans often have a network of providers that members must use and may require referrals for certain services.

That helps explain why certain physicians – perhaps even a primary care doctor you have been seeing for years – might suddenly be “out of network” if you sign up for a Medicare Advantage Plan. And Medicare Advantage plans may have different costs, such as monthly premiums, copayments, and deductibles, depending on the plan and the services used.

How to Make Sure Your Preferred Physicians and Other Care Providers Will Be Paid for by Your Medicare Advantage Plan

  • Check provider directories on the website of your plan provider. These are usually well organized by your geographical area and plan type, then searchable by physician specialties, name, and other criteria. Be sure to check whether the physician you are looking for is listed before you sign up for a plan. 
  • Call the insurance company that administers your plan and ask for assistance in finding physicians. Most all insurance companies have helpful phone representatives who can verify whether your preferred physician(s) are in their network. If the physician you are looking for is not, these representatives will be able to suggest other physicians near you who are in network – whether general practitioners or specialists.
  • Call your doctor’s office directly and ask if they are in the network of the Medicare plan you have or are considering. Sometimes even if the specific physician you are asking about isn’t, another one in the same practice could be. (“Your current primary care physician Dr. Jones doesn’t participate in your plan but Dr. Ramsey, who is also in this office, does.”)

What to Do If Your Doctor Isn’t Covered

Remember, you can change your Medicare plan during the annual enrollment period and during special enrollment periods, provided you meet certain requirements. 

To review:

You can enroll in Medicare during one of these periods: 

  • Initial Enrollment Period – Most people can first enroll in Medicare (Part A, B, C and D) during a 7-month window: 3 months before the month you turn 65, the month you turn 65, and three months after the month you turn 65
  • Medicare Part C & D Annual Enrollment Period (AEP) – between October 15 and December 7 every year, existing Medicare beneficiaries can use this period to re-evaluate and make changes to their Medicare Advantage (Part C) and Medicare prescription drug plans (Part D). You cannot use AEP to enroll in Part A and/or Part B for the first time.  If you enroll in a plan during AEP, coverage starts on January 1 of the following year.
  • Special Enrollment Period (SEP) – You may qualify for a special period the enroll in Medicare based on certain life events such as you change residence or lose current coverage.  Depending on your circumstance, you generally will have two full months to enroll.
  • Medicare General Enrollment Period (GEP) – January 1 to March 31, every year. Most people will enroll in Medicare Part B coverage when they first sign up for Medicare. GEP is reserved for individuals who chose not to enroll in Part B when they were first eligible. Coverage starts the first of the month after you apply.
  • Medicare Advantage Open Enrollment Period (MA-OEP) – January 1 to March 31, every year. MA-OEP is only for people who are enrolled in a Medicare Advantage plan as of January 1.  During MA-OEP, you can switch to a different Medicare Advantage plan with or without drug coverage or switch back to Original Medicare and join a standalone Medicare Prescription Drug plan.  You cannot switch from Original Medicare to a Medicare Advantage plan during this period.

CoverRight Will Help You Be Sure Your Visits to Your Preferred Doctors will Be Covered

CoverRight will do that for you, across all major plans and providers – and at no charge to you. 

Be sure to choose a Medicare plan that will cover the cost of going to the doctors you rely on, or the doctors you would like to see. There is no reason to be required to see physicians you do not like, whose offices are not close to where you live, who charge excessive co-pays or who otherwise don’t meet your needs.

CoverRight’s digital platform and licensed insurance agents will help you choose the right plan and avoid any headaches with your doctors.

Barry Lenson

Barry’s is an experienced writer who's most recent book projects have included "The Digital Health Revolution" and "Connecting Health Care," for which he served as writer and editor for the author Kevin Pereau. Barry’s own books include the self-help bestseller "Good Stress, Bad Stress." Barry writes blogs for Tortal Training, Ingage Consulting, Specialty Metals Smelters and Refiners, and other clients.

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