Medicare Advantage Plan No Longer Covers Your Health Care Provider? Learn What to Do!

What to do if your healthcare provider leaves Medicare Advantage and learn what is medicare advantage?

23 Jul Medicare Advantage Plan No Longer Covers Your Health Care Provider? Learn What to Do!

Posted at 08:00h in Medicare by Triage Cancer

If you have a Medicare Advantage plan and it no longer covers your health care provider(s), you may be wondering what your options are. Read this blog to learn more about what you can do, and when.

What are the Parts of Medicare?

Medicare coverage is broken down into 4 parts:

Part A: Hospital Insurance. Includes hospital care, skilled nursing facilities, nursing homes, hospice, and home health care.
Part B: Medical Insurance. Includes outpatient services, preventive care, labs, mental health care, ambulances, and durable medical equipment.
Part C: Advantage Plans. Part C is an alternative to Parts A and B and includes benefits and services covered under Parts A and B, and usually Part D. Plans are offered by Medicare-approved private insurance companies.
Part D: Prescription Drug Coverage. Plans are offered by Medicare-approved private insurance companies.

Part A and Part B are referred to as Original Medicare.

What are the Types of Medicare Payment Systems?

There are two Medicare payment systems when you receive health care:

Fee-for-service (FFS): a health care provider is paid a fee for each service provided. With FFS plans, you can go to any provider willing to see you. You pay for a portion of your care, and the insurer pays the rest. Medicare Parts A and B are considered FFS.
Managed Care: a health care provider contracts with a health insurance company to be a part of its network. If you go to a provider in the network, the provider has agreed to a certain payment rate for treating you (i.e., allowed amount). Regardless of what the provider bills, it’s that “allowed amount” that will determine your final cost. You typically pay a portion of the allowed amount, depending on your plan. Medicare Parts C and D are managed care plans.

What are the Types of Medicare Advantage Plans?

There are several types of Medicare Advantage Plans, and it is important to know which one may fit your needs the most.

Health Maintenance Organizations (HMO): An HMO plan is a type of Medicare Advantage Plan that generally provides health care coverage exclusively from doctors, other health care providers, or hospitals in the plan’s network. Since HMOs coordinate care, your primary care provider must give you a referral to see a specialist.
Preferred Provider Organization (PPO): A PPO plan has a network of doctors, specialists, hospitals, and other health care providers. You can also get health care from out-of-network providers, but usually for a higher cost.
Private Fee-for-Service (PFFS): A PFFS plan determines how much it will pay doctors, hospitals, and other health care providers as well as how much you must pay when you get care. If your plan has a network, you can use any of the providers within the network, but if there is not a network for your plan, you can go to any Medicare-approved doctor or hospital that accepts the plan’s terms.
Special Needs Plan (SNPs): A SNPs plan provides benefits and services to people with specific diseases, certain health care needs, or who also have Medicaid coverage. SNPs tailor their benefits, provider options, and medications they cover to meet the specific needs of the groups they serve. There are three types: Chronic condition, Institutional, or Dual Eligible SNP.
Medical Savings Account (MSA): MSA plans combine a high-deductible insurance plan, which only cover your costs once you meet a high yearly deductible, and a medical saving account. The MSA plan deposits money in your account that you can pay health care costs.

Where Can I Find My Medicare Advantage Plan’s Provider Network?

You can find your plan’s provider directory on your Medicare Advantage Plan’s website, or you can contact your plan to request a physical provider directory.

How Do I Know If I’m Going to Lose Coverage?

Your Medicare Advantage Plan can add or remove providers from its network at any time throughout the year.

However, while your plan can change, your plan must protect you from interruptions in your medical care and make sure you have access to medically necessary covered benefits. Your plan will notify you of any changes that they make with providers.

Your health care provider can also choose to leave your plan’s network at any time.

Your plan should provide you with at least a 30 days’ notice that your provider is leaving your plan, so you can have time to select a new provider.

During Medicare’s Open Enrollment Period (October 15 – December 7), you can check if the plan you currently have, or any plans you are considering, include your provider(s) in their network.

What If My Provider Will No Longer Be Covered?

If your provider is no longer in your Medicare Advantage plan’s network, you have two options. You can find new providers who are in-network or you can pay out of pocket to continue to see your providers.

To find new providers who are in-network, you can find your plan’s provider directory on their website, or contact them by phone to request a physical directory.

What If I Want to Change My Plan?

If you would like to change Medicare Advantage plans, you can do so during the Open Enrollment Period, the Medicare Advantage Open Enrollment Period, or a Special Enrollment Period.

Open Enrollment Period: occurs between October 15 and December 7, every year. During this time, anyone with Medicare can join, switch, or drop a Medicare Advantage plan with new coverage beginning on January 1.
Medicare Advantage Open Enrollment Period: occurs between January 1 and March 31, every year. During this time, you can switch from a Medicare Advantage Plan to another Medicare Advantage Plan, or you can drop your Medicare Advantage Plan and return to Original Medicare. You can only make one change during this period, and the plan will be effective on the first of the month, after your plan gets your request.
Special Enrollment Period: occurs for special circumstances like moving or losing insurance coverage. Contact Medicare to see if you qualify for a special enrollment period. You may be able to argue that you should qualify for a special enrollment period because there has been “significant network changes” to your plan.

For more information about Medicare, visit Triage Cancer’s Medicare Resources.

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