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Do All Hospitals Accept Medicare Advantage Plans?

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By Daniel Petkevich
Apr 11, 2023

Your plan may limit your access to a particular network

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Medicare Advantage plans offer additional coverage beyond what Original Medicare provides and have an out-of-pocket limit, which can be attractive for individuals on a fixed budget. However, the question that often arises when considering Medicare Advantage plans is whether all hospitals accept them.
Let's take a closer look at Medicare Advantage plans, including their costs and whether all hospitals accept them.

What Are Medicare Advantage Plans?

A

Medicare Advantage Plan

, also known as Medicare Part C or MA Plan, is an alternative option to Original Medicare (Part A and Part B). These plans are offered by Medicare-approved private insurance companies and must adhere to Medicare regulations.
They cover all services under Original Medicare and may also provide additional coverage for services like

vision

, hearing,

dental

, prescription drug coverage (Medicare Part D) and more.
While

Medicare Advantage Plans

may limit your options to a network of healthcare providers, they do offer the benefit of an annual out-of-pocket maximum for Medicare-covered services. This means you'll have a yearly cap on your Medicare expenses even if you require extensive medical treatment.

How Do Medicare Advantage Plans Work?

When you enroll in a Medicare Advantage Plan, the company offering the plan receives a fixed monthly payment from Medicare for your coverage. These companies must abide by Medicare's regulations, but each plan may have different out-of-pocket expenses and rules for accessing services.
For example, you may need a referral to see a specialist or be limited to doctors or hospitals within the plan's network (excluding emergency and urgent care situations).
It's important to stay informed, considering these rules may change annually. Fortunately, it's a prerequisite that each plan provides advance notice of any changes to all members before the next enrollment period.

What Are MAPD Plans?

MAPD, or Medicare Advantage Prescription Drug Plan, is a Medicare Advantage Plan that includes coverage for prescription drugs. In addition to the standard Medicare benefits and prescription drugs, MAPD plans may also offer additional benefits such as vision, hearing, and dental coverage.
While some MAPD plans may limit coverage to in-network services, others may also cover out-of-network healthcare services. However, using providers outside your plan's network may increase out-of-pocket expenses or result in a lack of coverage, depending on your plan details.

What Are the Types of Medicare Advantage Plans?

There are five main types of Medicare Advantage plans, but not every plan is available in your area. You may find all, some, or none of these plans available depending on where you live. You may also find multiple plans of the same type if private companies in your area decide to provide them.
Let's look into the different types of Medicare Advantage Plans**.**

1. Health Maintenance Organization (HMO) Plans

An HMO plan generally only provides coverage if you get medical care from doctors, hospitals, and other healthcare providers within your plan's network. There are exceptions, such as emergency care, out-of-area urgent care, or out-of-area dialysis. You'll always be covered for emergency and urgent care.
Some HMO plans may have a Point-of-Service (POS) option that allows you to receive certain out-of-network services, but this usually comes at a higher cost.
It's worth noting that most HMO plans require you to have a referral from your

primary care doctor

if you need to see a specialist.

2. Preferred Provider Organization (PPO) Plans

PPO plans

offer more flexibility than HMO plans. You can receive healthcare services from providers outside the network, but they are often more expensive.
Note again that you'll always be covered for emergency and urgent care.

3. Private Fee‑for‑Service (PFFS) Plans

PFFS plans have two types: one with a network and the other without.
In PFFS plans that don't have a network, you can typically go to any Medicare-approved doctor, hospital, or healthcare provider who accepts the plan's payment terms and agrees to treat you.
However, in PFFS plans that do have a network, you can typically see any provider within the network who has agreed to treat you. You may also be able to receive care from an out-of-network provider who accepts the plan's terms, but it may cost more.
Either way, you'll always be covered for emergency and urgent care.

4. Medicare Special Needs Plans (SNP)

Special Needs Plans (SNPs) are specifically designed to help Medicare beneficiaries who meet unique criteria. There are three types of SNP plans: Chronic Condition (C-SNP), Institutional (I-SNP), and Dual Eligible (D-SNP). These plans customize their benefits, provider choices, and list of covered drugs (formularies) to best serve their target group's specific needs.
For instance, an SNP may provide additional coverage for extra hospital days if you have a chronic or severe health condition like cancer or heart failure.
While some SNPs may require you to choose a primary doctor within the network, they typically have specialists available to treat the specific conditions of their members.

5. Medical Savings Account (MSA) Plans

Medicare MSA Plans offer an alternative to traditional Medicare coverage. They combine a high-deductible health plan with a medical savings account. The Medicare MSA Plan deposits money into this account, which you can use to pay for your healthcare expenses.
The amount of money deposited into the account will vary depending on your plan. One of the benefits of the MSA is that you can use this money to pay for your Medicare-covered costs before you meet your deductible.

How Much Do Medicare Advantage Plans Cost?

Medicare Advantage Plan premiums are dependent on the specific plan you choose. While some Medicare Advantage plans may offer a zero premium, it's important to note that you will still be responsible for paying the Medicare Part B premium ($164.90 in 2023).
The deductibles, copays, and coinsurance will also vary from plan to plan.
Fortunately, many Medicare Advantage plans come with an out-of-pocket limit. Once you reach this limit for the year, your plan will cover 100% of the approved healthcare services for the remainder of the year.
However, MAPD plans have no out-of-pocket limit on outpatient prescription drugs. This means there is no hard cap on your outpatient drug expenses. But,

Catastrophic coverage

can help reduce your out-of-pocket spending once you enter that stage.
Furthermore, Medicare beneficiaries enrolled in a Medicare Advantage Plan do not need to pay the Part A and Part B deductibles separately. Instead, they must pay their Medicare Advantage plan's deductible (if any).
For example, in case of hospitalization, individuals with a Medicare Advantage plan are not required to pay the Part A deductible or copays. Instead, they pay their plan's deductible (in case it has not been fulfilled yet) along with their daily copays for hospital care. The deductibles and copays differ according to the plan.

Do All Hospitals Accept Medicare Advantage Plans?

While most hospitals do accept Original Medicare, there may be some that do not accept Medicare Advantage Plans.
However, if you have a medical emergency while you're enrolled in a Medicare Advantage plan, you can seek care at any ER or hospital in the country. Your Medicare Advantage plan will cover the emergency services as if they were in-network, even if the hospital or provider is out-of-network. But a copay and coinsurance may be involved in each visit and service obtained.
On the other hand, if you receive non-emergency care from an out-of-network provider, your Medicare Advantage plan may not cover the full cost of care, and you may be responsible for paying a more significant portion of the bill.
Mayo Clinic recently notified its eligible Medicare beneficiaries in Arizona and Florida that it's no longer in-network with most Medicare Advantage plans. Furthermore, they have stated that they will not be able to schedule appointments for patients with Medicare Advantage plans that are out-of-network.
It's advisable to seek medical care from healthcare providers within your network to minimize the risk of unexpected costs. Also, contact your hospital before scheduling in-patient stays to confirm if they accept your Medicare Advantage insurance.

Maximize Your Savings by Staying Within the Network

Private insurance companies approved by Medicare offer Medicare Advantage Plans. These plans cover all services under Original Medicare and may also provide additional coverage for services like vision, hearing, dental, prescription drug coverage, and more.
However, not all hospitals accept all Medicare Advantage Plans. In addition, to get full coverage for your healthcare services, you may need to limit your options to a network of healthcare providers. Some plans allow for out-of-network coverage, but this can be expensive.
If you're in a Medicare Advantage Plan, staying within your network is advisable to get maximum benefits from your health insurance. But if your preferred healthcare provider has moved out of your network, or you're not satisfied with your current plan, you can

change your plan

during the

Annual

Enrollment Period.

On the other hand, if you're planning to join a Medicare Advantage plan, select a plan with a network that includes desired healthcare providers in your area.Analyzing all the aspects of a plan and selecting the best one for you can be overwhelming. Our advisors are well-versed in the minutiae of the plans and can help you make the right choice.
Over the years, we've assisted several Medicare beneficiaries in choosing the right plan. If you need help selecting a plan, call us at 1-888-376-2028, and one of

our advisors

will be happy to guide you through the process.

Stay Up to Date on Medicare!

Join the Fair Square Medicare Newsletter to stay informed on cost savings, changes to Medicare, and other valuable healthcare information.

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Virgil Insurance Agency, LLC (DBA Fair Square Medicare) and www.fairsquaremedicare.com are privately owned and operated by Help Button Inc. Medicare supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program. This is a solicitation of insurance. A licensed agent/producer may contact you. Medicare Supplement insurance is available to those age 65 and older enrolled in Medicare Parts A and B and, in some states, to those under age 65 eligible for Medicare due to disability or End-Stage Renal disease. Virgil Insurance Agency is a licensed and certified representative of Medicare Advantage HMO, HMO SNP, PPO, PPO SNP and PFFS organizations and stand-alone PDP prescription drug plans. Each of the organizations we represent has a Medicare contract. Enrollment in any plan depends on contract renewal. The plans we represent do not discriminate on the basis of race, color, national origin, age, disability, or sex. Plan availability varies by region and state. For a complete list of available plans please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov. © 2024 Help Button Inc

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