Question: I just found out that one of my providers is no longer in network for my Medicare Advantage Plan. What are my options?

Answer: There are many important factors to consider when learning to understand your insurance and the coverage it provides you. When you have Medicare and a Medicare Advantage Plan, you must also 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 with your HMO Medicare Advantage Plan. You can find that In-Network provider by reaching out to the insurance company use the company website to find alternative providers in your region who are in-network. IF you have an Special Enrollment Periods (SEP) available, you could also consider switching your insurance coverage.

Right now, there is not an open enrollment period available for you to switch your insurance to another type of plan, so you would need an SEP to make that change. If you have an SEP available and you chose to change your insurance, your new plan would begin the first of the following month.

For many individuals enrolled into a Medicare Advantage HMO Plan, they don’t have an SEP’s available, so their only option is to find a new provider who is in-network. That Can be frustrating, as you have a history with that provider and don’t like the idea of starting over with a new provider.

When you have a PPO plan, you have many more options in this situation. A PPO plan allows you to use both in 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 Specialist Physician is in-network the cost is usually $10-$75 depending on the plan you are enrolled in. If you see a Specialist Physician that is out of network that cost can be 33-50%. Additionally, you may have trouble getting tests and procedures ordered by that out of network specialist. Your Medicare Advantage Plan may have additional protocols that make coverage for those tests more difficult to obtain.

So while using an out of network provider with a PPO is allowed, 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 PPO plan, but you must understand how it could impact your pocketbook and budget.

There are also situations when a provider (doctor, hospital or other) could decline to accept your PPO Plan. While the insurance company may be willing to work with that provider as an out of network provider, but the provider themselves may not be willing to work with YOUR insurance company. In this situation when the provider finds you have this type of Medicare Advantage Plan, they may inform you that you cannot be seen at this time with that type of Medicare Advantage Plan from that particular company.

If this happens, the only way to see that provider would be to change your insurance coverage when and if you are allowed to, using an SEP or an Open Enrollment Period as they are available to you. 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. 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.