Saying Hello to Medicare Advantage Could Mean Saying Goodbye to Your Doctor

While a lower monthly premium and all-inclusive prescription drug coverage can make Medicare Advantage (MA) plans an attractive option over traditional Medicare, these plans can drastically limit your health care network. This could mean saying goodbye to trusted doctors and providers you’ve known for years who may not be included in your Medicare Advantage plan’s network.

Network Limits

Unlike traditional Medicare that lets you see almost any doctor anywhere in the country, Medicare Advantage plans limit how and where you get care because they restrict your choice of doctors and hospitals to ones they’ve picked.

Only 46 percent of doctors that accept traditional Medicare accept some Medicare Advantage plans.

This means that if your local doctor is not in the Medicare Advantage plan’s network, you may have to travel far from home for care you would have been able to get here at home with traditional Medicare.

Network restrictions also limit your ability to receive care when travelling. If you’re visiting grandchildren and need medical care, you may not be able to get it because your plan doesn’t include doctors in that town. Same thing if you’re on vacation. Traditional Medicare, on the other hand, allows you to see any doctor virtually anywhere in the country.

Prior Authorization and Coverage Denials

Even if your doctor is included in your Medicare Advantage plan’s network, Medicare Advantage plans can limit the care your doctor can provide.

99 percent of Medicare Advantage plans require prior authorization for services covered by traditional Medicare, like skilled nursing, short-term hospital stays, and durable medical equipment.

This means your doctor must get permission from your Medicare Advantage plan before you can get recommended medical equipment or treatment, such as oxygen equipment, surgery, or physical therapy. The Medicare Advantage plan staff making these care decisions typically are not physicians and may not be medical professionals at all.

Each Medicare Advantage plans also uses its own guidelines to make coverage decisions, and these guidelines are not the same used by traditional Medicare. The result is that Medicare Advantage plans deny coverage much more often than traditional Medicare, including care that traditional Medicare covers.