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Question: I just received a letter that my primary care provider is no longer in network for my Medicare Advantage Plan. What are my options?
Answer: We have gotten a LOT of calls about this situation and you may remember an article I wrote about a month ago. This situation can happen because your provider decided to leave the insurance company, OR your insurance company dropped that provider, OR because the contract is in negotiations OR the contract between the insurance company and your physician did not get signed in a timely manner.
First I want to say that the situation that happened locally with Family Health Medical and Aetna Medicare Advantage Plans has been resolved. Family Health Medical is back In Network for Aetna Medicare Advantage Plans.
The other group that we are hearing this about is Western New York Urology. They have a new name Great Lakes Urology and that new company is busy setting up contracts with the insurance companies in the region. They anticipate that the local insurance companies and the new company Great Lakes Urology will work out their contracts and will all be in network by the first of the year.
I believe your concerns related to these two situations are resolved at this time. But we can look into this topic a bit further, which is a review from last time.
When you have Medicare and a Medicare Advantage Plan, you must understand the type of Medicare Advantage Plan you have. There are HMO's (Health Maintenance Organizations), and PPO's (Preferred Provider Organizations).
When you have an HMO, you have coverage at in-network providers only. That means the plan will only help you pay for medical care when you use in-network providers.
In-network means these providers have contracts with, and agree to participate in, the HMO product you are enrolled in.
If you go to providers who are not contracted with, or have left the plan (broken the contract), your HMO insurance will not help cover any part of that medical care.
To answer your question: if you have an HMO Medicare Advantage Plan, your options are to find a new in-network provider within your HMO Medicare Advantage Plan. You can find that In-Network provider by reaching out to the insurance company or by using the company website to find alternative providers in your region who are in-network.
You also have the option to find a different insurance product. Right now, we are heading into the Annual Enrollment Period (AEP) which would allow you to switch your insurance to another type of plan.
When you have a PPO plan, you have many more options in this situation. A PPO plan
allows you to use both in network and out of network providers. However, the cost you pay will be different and sometimes significantly higher. You need to understand that cost difference. When a Primary Care Physician is in-network the cost for an appointment is usually 0-10 depending on the plan you are enrolled in. If you see a Physician that is out of network that cost can be higher, maybe $30, $45 or as high as 50% co-insurance. Your Medicare Advantage Plan may also have additional protocols which could make it more difficult to get coverage for tests and procedures when they are done out of network.
If you have a PPO, you don't need to change your provider, it does change the cost structure and potentially the process for additional tests and procedures approved, which is important to understand. You may not have to change your provider or your insurance coverage when you have a PPO plan, but you must understand how it could impact your pocketbook and budget.
I believe this situation has been resolved this year and you don't need to change products or providers because of this situation. But you still have the AEP (Oct 15 to Dec 1) to evaluate your coverage and change if you wish.
We have seen these network changes happen recently with a number of providers, and companies. This can be very disruptive for you, the individual. That is especially true when you find out close to your appointment, and sometimes even as you arrive for your appointment. Talk with your doctor's office. Reach out to your insurance company for support. Reach out to the individual who helped you to choose that insurance product for you. You can also reach out to Medicare at 1-800-MEDICARE to help get some alternatives.
Janell Sluga is a Geriatric Care Manager helping seniors in our community access services and insurance. To reach her, please email editorial@post-journal.com.