Medicare Doctor does not Mean Medicare Advantage Doctor

Medicare Advantage plans are a popular alternative to regular Medicare because the plans often offer lower out-of-pocket costs, but buyers need to make sure they know what they are paying for.

The other day, I made a rare visit to a doctor’s office. Consistent with past experience, I had plenty of time in the waiting area. Since it is early in the year, many people were coming to this doctor for the first time in 2017.

As I sat there, I noticed a common theme. For this year, many people shifted from the normal Medicare plan to a Medicare Advantage plan. I also observed, many people did not understand what that met. And worse, they just found out the doctor was not in network.

What is the “Advantage”

Medicare Advantage plans are a popular alternative to regular Medicare because the plans often offer lower out-of-pocket costs, but buyers need to make sure they know what they are paying for. Do you remember your old HMO or PPO plan? Think of that when you think of Medicare Advantage plans.

Medicaid Advantage is not your father’s Medicaid coverage. In reality, it isn’t even the coverage you may have received in a previous year. It is a public/private partnership between the Government and Private Insurance Companies to lower the cost of the Government to provide the required insurance program.

Insurance companies like Aetna, UnitedHealthcare, and Humana contract with the Government to manage the healthcare “insurance” plan for those who join the Medicare Part C program instead of Medicare Part A and B.

The companies make it very attractive by bundling low office visit cost, folding in your Part D (prescription) Plan coverage. Plus, they enhance the plan by offering add-ons for Vision, Dental, etc., all for one monthly premium. The government pays Medicare Advantage plans a fixed monthly fee to provide services to each Medicare beneficiary under their care. These plans are usually health maintenance organizations (HMOs) or preferred provider organizations (PPOs) that only cover care provided by doctors in their network or charge higher rates for out-of-network care.

What is the Issue

The plans often look attractive because they offer the same basic coverage as original Medicare plus some additional benefits and services that original Medicare doesn’t offer.

However, what may not be clear during the enrollment period is that a doctor who takes Medicare patients, may not take ALL Medicare Advantage patients…if any.

To confuse things more, a recent discover revealed that the Insurance Companies’ online provider directories were often riddled with errors. So, when a person checked to make sure his or her doctor, pharmacy, etc. was in the Medicare Advantage Network, the list may have been wrong. Now, the Government could charge those plans serious fines. Unfortunately, the person who signed up had to choose whether to pay the out-of-network premium charge to see his or her doctor or find a new one.

What Can Be Done

Because Medicare Advantage plans have different coverage rules for out-of-network care, it is important to know which doctors and hospitals are in a plan’s network. Recently, the Centers for Medicare & Medicaid Services (CMS) conducted a review of online provider directories for Medicare Advantage plans and found that there was incorrect information for half of the 5,832 doctors listed in directories for 54 Medicare Advantage plans that represented a third of all Medicare Advantage providers.

As a result of the review, CMS warned 21 Medicare Advantage insurers to fix the errors by February 6, 2017, or face serious fines. In 2016, CMS enacted a rule requiring plans to contact doctors and providers every three
months to update their online directories. A Medicare Advantage plan can face a penalty of up to $25,000 a day per beneficiary if errors aren’t corrected.

The decision is done for this year. But, when considering your choice during the enrollment period later this year, be sure you double-check with the doctors and hospitals you use that they are covered by the Insurance Plan you consider. Remember also, Advantage plans have different networks. Ask specifically.

If you have a question and want to make plans for later this year, give me a call. You can sign-up for a free, 30-minute consultation during the call or by using the form on this page.

Additional information on this topic can be found at or about errors in Medicare Advantage plans.

About the author

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Founder/Attorney, CCSK Law
I create customized solutions for families to address their planning needs.
I provide plans clients understand. Also, they make sure they know when to use them, and do so affordably. I love the opportunity to break through the legal jargon to clarify issues. We find success when we work through a person’s situation and put the law to work for them.

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