One of the most common concerns people have when going on Medicare is whether or not they’ll be able to go to any doctor or health care provider they want. If you’ve been wondering the same thing, you’re in the right place! Today, we’re going to answer this question by explaining which two Medicare options are available, and what doctors you can choose from within these two options.

Two Medicare Options

The simple answer to the question, “Can I go to any doctor when I’m on Medicare?” is maybe, or maybe not. It all depends on which insurance option you select when you start taking Medicare benefits. There are only two options when you go on Medicare. You can either 1) stay in the original Medicare system by enrolling in Medicare A & B (within this system you’ll get a Supplemental plans like F, G, N, etc.) or 2) enroll in Medicare A & B but get a Replacement plan called an Advantage Plan (also referred to as Part C Plans).

Let’s talk a little more about how these two Medicare options work and how they affect your ability to choose doctors and health care providers.

Medicare Option #1

If you enroll in Medicare and choose to stay within the original Medicare option (A & B plus a Supplemental Plan like F, G or N), Medicare is in the first payor position. Within this original system, Medicare gives you the freedom to choose any provider that you want as long as they take Medicare. So any hospital, specialist, or doctor is available to you as long as they accept Medicare. There are no networks restrictions beyond this. The Supplemental plans offered by the insurance companies  in and of themselves do not have networks. It’s called Open-Access.

Medicare Option #2

When you choose Medicare option #2, you’re bypassing the original Medicare benefits, and instead, using a private health insurance company. If you go this route, choosing a doctor or health care specialist isn’t as straightforward as simply finding someone who accepts Medicare. Rather, you’re now in a Medicare Advantage network plan, meaning you have to find providers who are within that network. Now, this can still gives you plenty of health care provider options, but there are restrictions.

To better understand why you have restrictions and what it means to choose a health care provider within the Medicare Advantage network, let’s talk briefly about how these networks operate.

Medicare Advantage Networks

There are two different networks within the Medicare Advantage plan system. The first one is what we call HMO. HMO stands for health maintenance organizations. The other network is called PPO and it stands for preferred provider organizations. These two networks differ in four essential ways, and it’s important for you to be clear on these differences so you know what to expect (and which doctors are available to you) if you go with an advanced Medicare plan.

Size of Network

First, the size of the HMO and PPO networks are very different. The HMO network is smaller than the PPO network, meaning if you’re in the HMO network system, you have fewer choices when it comes to selecting a doctor or health care provider. The reason for this is that providers within the HMO network have a smaller reimbursement rate than providers on the PPO network plans. Some doctors don’t want to see patients for less money, meaning they won’t join the HMO network.

While the HMO network is smaller and you have less health care provider options to choose from, many people still choose this network because even though they have fewer choices, they are given lower copays and lower max out-of-pocket costs. So for many people, the HMO network lower copays and out of pocket costs make up for the lack of network size.

Referrals

The second difference between HMO and PPO networks is referrals. Most HMO plans require that you see your primary care doctor first before you can go see a specialist doctor, like your cardiologist, dermatologist, rheumatologist, etc. Within this system, you can’t make the appointment to see a specialist yourself. Instead, your primary doctor will have to do that. Now, not all HMO plans require this, but many do.

PPO Advantage plans, on the other hand, never require a referral. If you want to go see your cardiologist or dermatologist (or another type of specialist), all you have to do is pick up the phone and schedule an appointment. (Provided of course, the specialist is in the plan’s network).

Out Of Network

The third difference between HMO and PPO networks is their out-of-network benefits. If you’re on an HMO plan, you don’t have the right to go out of the network. In other words, you must always stay within your network of providers.

On a PPO plan, however, you are allowed to see other providers outside of your network as long as they accept Medicare. Now within the PPO system, it will cost you a little more to go out of network. Say your annual max out of pocket within the PPO network is $5,000. If you venture out of your network that may bump you up to $7,000 to $10,000 annual out of pocket costs. So in the PPO network, you do have the privilege of going out of the network if you’d like to, you’ll just have to pay a little more for it.

Urgent Care & ER

Within both the HMO and PPO networks, you never have to worry about staying within your network when visiting an Urgent Care or Emergency Room. This one just makes sense because no one should have to worry about their network when they’re having a heart attack or some other urgent health issue. So whether you’re in the HMO or PPO network of providers, you can go into any Emergency Room or Urgent Care anywhere in the world, and you’ll be taken care of. However, beyond these emergency visits, you will have to stay within the network rules.

Can You Go To Any Doctor When You’re on Medicare

So when you’re on Medicare, can you go to any doctor? If you’re staying on the original Medicare plans A & B (plus any Supplemental plan), then yes, you are free to choose any health care provider as long as they accept Medicare.

If you decide to go with an advanced Medicare plan (Medicare Replacement or Advantage plans), you’ll have to choose a doctor or health care provider within specific networks. The two networks, HMO and PPO, both have unique differences. Depending on which network you’re in, you’ll have different guidelines and a specific selection of doctors to choose from.

We understand how difficult making the right Medicare decisions can be.  To take the next step, click here to watch our full course or schedule a free one-on-one call with a certified Medicare School Guide who can answer your questions, compare plans options, and even help you enroll. Click here to schedule an appointment.

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