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Can Your Doctor Stop Accepting Your Medicare Advantage Plan?

Can Your Doctor Stop Accepting Your Medicare Advantage Plan?

The title of this blog entry is a very reasonable question many people ask. We all want assurance that our insurance will cover us when we need it. Let's take a look at what a Medicare Advantage plan is basically, and the answer to our title above. 

A Quick Definition

A Medicare Advantage is an alternative to Original Medicare coverage. It may occasionally be called a Medicare Health Plan or Part C, and in any event, Medicare Advantage Plans are health plan options that are approved by Medicare and managed by private companies.

Let's look closer. As we indicated above, unlike Original Medicare which is provided by the federal government, Medicare Advantage plans are indeed Medicare-approved plans, but a key difference is that they are offered through private insurance companies. Individuals on Medicare Advantage plans can see doctors within their plan’s regional service area who are under contract with their plan.

There are also different models of Medicare Advantage plans, all of which have their own guidelines for the type of providers and services that are covered under the plan. These models are Medical Advantage Health Maintenance Organizations (HMOs), Medicare Advantage Preferred Provider Organizations (PPOs), Private For-for-Service Plans (PFFS), and Special Needs Plans (SNP). Whew - that's lot of acronyms! Not to worry... your insurance advisor can help you sift through them.

The Final Word on Doctors

While it is rare for a doctor to stop accepting a Medicare Advantage plan, it could happen. The most common reason that doctors may discontinue their acceptance of Medicare Advantage is that the private insurance company makes it difficult or time-consuming for the doctor to get paid for their services.

In addition, while not all Medicare Advantage plans require you to use doctors in its provider network, many of them do. You can find whether your plan allows you to use providers outside of its network by checking your rules about coverage or contacting our experts for assistance. A bit of advice: Watch out if your Medicare Advantage plan allows you to seek treatment from providers outside of the plan network; this may offer great flexibility, but you are likely to be charged a higher copayment or coinsurance amount.

Can Medicare Advantage Plans Drop You?

First up, Medicare Advantage plans can’t drop you because of a medical condition. That being said, there are two valid reasons that you may be dropped by your plan: 1), you may be dropped if your plan stops providing services in your region; 2), you may be dropped if for some reason your premiums are not paid within the specified grace period.

If you are dropped by your Medicare Advantage plan, it will be important to investigate why and plan what you'd like to do going forward. Our Medicare benefits consultants can connect you with a plan that meets your unique needs and help you each step of the way.


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