This month I'm writing about networks. This will be a challenge because according to regulations, I am not allowed to mention company names or plan specifics. So please reach out to me if you have any questions about your current situation.
With traditional Medicare, a person is allowed to see any doctor who accepts Medicare reimbursement, and approximately 80 percent of the cost will be paid by Medicare. The remaining 20 percent can be covered by a Medicare Supplement.
With Medicare Advantage, the paradigm is completely different. Every month that you are on a plan, the government pays your insurance company a sum of money, and then your company pays 100 percent of your covered benefits minus a list of co-pays. However, with these type of plans you may be restricted to a network.
Each company has a different approach to networks. There are many styles of plans available in Carroll or Oxford (Maine) counties. There are HMOs, PPOs, HMO-POS and RPPOs. Of these, the most restrictive are the HMOs (health maintenance organizations).
With an HMO, you must see an in-network provider or the company will not pay your claim. Sometimes you need a referral from your primary-care doctor, but not all companies require that.
A PPO (preferred provider organization) allows you to see out-of-network providers. Some plans charge you a higher co-pay, others don’t. Some plans have higher out-of-pocket maximums when out of network. Often, this feature allows you to see a specialist you have been seeing in the past but for a higher co-pay than an in-network specialist. Sometimes paying more is worth it.
An HMO POS (HMO point of sale) policy allows you to go to out-of-network doctors who will accept Medicare reimbursement.
An RPPO is a regional PPO that allows you to go out of network within a defined region (like New Hampshire, Maine and Massachusetts). Again, the provider must be willing to accept Medicare reimbursement.
Each company has a different approach to networks. One company has networks in 30 states. You can call them up and say, “I am spending the winter” in a covered state. They then allow you to use their network in that state while you are there. Other companies have networks dotted around the nation, but are stronger in some places than others. Another company has networks in only New Hampshire and Maine.
The point is, not all networks are the same, and it is your job to stay informed!
So which company is your best fit may depend on your lifestyle. If you are a snowbird, you want a company that will cover you in both places. Always remember that on most plans, you are covered worldwide for both emergency care and urgent care with no need to be in network. Urgent care is when you are sick and see a doctor at a walk-in clinic.
I suggest you work with a licensed, appointed and certified agent to solve this puzzle. Ask her or him to look up your doctors to see if they are in-network for each possible plan.
Also ask about hospitals. Do you want to go to Mass. General, Maine Medical or Mary Hitchcock? Dana Farber is not in many networks but they do have local affiliates like MaineHealth. Quite often, little nuances will shift your choice from one company to another, or from one plan to another. Your task is to figure out which plan best meets your needs.
Bert Weiss is a life and health insurance agent licensed in New Hampshire and Maine, focusing on Medicare Advantage. He writes about the basic components to help the public understand how to manage Medicare insurance choices.