Can Medicare Advantage Plans be Used Out of State?
By Daniel Petkevich
Jun 12, 2023
Read this before leaving for summer vacation
Are you planning a summer getaway or a visit to your grandchildren across state lines? If you're a beneficiary of a Medicare Advantage Plan, you might be worried about whether your plan has got you covered outside its service area. Whether you're an avid traveler or someone who occasionally steps outside your local area, understanding your healthcare coverage becomes vital.
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This blog post aims to unravel the complexities surrounding the usage of Medicare Advantage Plans outside their service areas. While some plans may cover out-of-network providers or those out of your service area, they often come with higher cost-sharing such as copayments and coinsurances. There might also be additional rules or restrictions like prior authorization to consider. Note that these plans are obligated to cover emergency and urgent care across the U.S. without imposing additional costs or coverage rules. So, before you pack your bags for that long-awaited trip, let's delve into the specifics to ensure you have a firm grasp on what to expect from your Medicare Advantage Plan when you're away from home.
Understanding Medicare Advantage Plans
We have talked at length about Medicare Advantage plans, but let's go through a quick refresher just in case.
Medicare Advantage Plans
, also known as Part C, are an 'all-in-one' alternative to Original Medicare. These plans are offered by private insurance companies approved by Medicare. They include Part A (Hospital Insurance) and Part B (Medical Insurance), and usually Part D (Prescription Drug coverage). Essentially, they are required by law to provide the same benefits as Original Medicare but can also offer additional benefits like vision, hearing, and dental coverage.
Medicare Advantage Plans come with their own set of benefits and drawbacks. On the positive side, they often provide more comprehensive coverage compared to Original Medicare, with most plans covering prescription drugs. They may also cover additional services like routine vision, hearing exams, or wellness programs. Plus, these plans have an annual out-of-pocket limit, protecting you from excessive costs. If you have a low monthly premium and low annual out-of-pocket limit, they could
save you money when compared to Medicare Supplement
, depending on the plans available in your area.
However, they're not without drawbacks. One significant limitation is the network restrictions - you may have to use healthcare providers within the plan's network for non-emergency or non-urgent care. Otherwise, you might have to pay more or even the full cost. Also, you may need a referral to see a specialist. Furthermore, if you enroll in a Medicare Advantage Plan, you can't use a Medigap policy to cover your out-of-pocket costs.
There are several types of Medicare Advantage Plans, each with different network rules, the two most common being
HMO and PPO
Health Maintenance Organization (HMO) Plans: With HMOs, you typically can only go to doctors, specialists, or hospitals on the plan's list except in an emergency. You may also need to get a referral from your primary care doctor to see a specialist.
Preferred Provider Organization (PPO) Plans: PPOs give you the freedom to go to any doctor, specialist, or hospital that accepts Medicare, not just the ones in the plan's network. However, going out of network might cost more.
Special Needs Plans (SNPs): SNPs provide specialized care for specific groups of people, like those with certain chronic diseases. All SNP plans must provide Medicare prescription drug coverage.
Private Fee-for-Service (PFFS) Plans: PFFS plans determine how much they will pay providers and how much you must pay when you get care. You can go to any Medicare-approved doctor, specialist, or hospital that accepts the plan's payment terms and agrees to treat you.
Medical Savings Account (MSA) Plans: These are high-deductible health plans combined with a bank account. Medicare deposits money into the account, and you can use it to pay for your healthcare services.
Knowing the difference between these plan types can help you make a more informed decision about which plan best suits your needs, especially if you frequently travel or live in multiple states.
Can Medicare Advantage Plans be used out of state?
Medicare Advantage Plans are tied to specific geographic areas due to their network of providers. In general, if you leave your plan's service area, your coverage for non-emergency or non-urgent care may be limited or not covered at all. This limitation is especially true for HMO plans that usually only cover care from providers within their network, except in emergencies or urgent situations. However, PPO plans provide more flexibility, allowing you to see doctors or visit hospitals out of the network, but often at a higher cost.
Some plans may offer out-of-state or even nationwide coverage, which is particularly useful for those who travel frequently or live in different states throughout the year. It's crucial to review your plan's coverage rules and network restrictions before traveling out of state to avoid unexpected costs or gaps in your healthcare.
Despite these restrictions, there are specific exceptions where your Medicare Advantage Plan will cover out-of-network or out-of-state care.
Emergencies: In the case of an emergency, Medicare Advantage Plans are required to cover your care anywhere in the U.S. without additional charges beyond what you would pay in-network. Once your condition is stabilized, however, your plan may require you to be transferred to a network hospital for further care.
Urgent Care: Urgent care needed for sudden illnesses or injuries that aren't life-threatening but need immediate attention is also covered anywhere in the U.S.
Dialysis: If you have End-Stage Renal Disease and need dialysis when you're temporarily outside your plan's service area, your plan must cover your dialysis.
It's important to remember that while these exceptions exist, it's always a good idea to contact your plan directly to understand how it handles out-of-state care and to avoid potential billing surprises.
Choosing a Medicare Advantage Plan with Out-of-State Coverage
When selecting a Medicare Advantage Plan with out-of-state coverage, you'll want to consider a variety of factors:
Network Restrictions: Consider the size and spread of the provider network. Some plans may have a larger network or even offer nationwide coverage.
Cost: Assess the costs of the plan, including the premiums, deductibles, and out-of-pocket maximums. Remember that out-of-network services may come with higher costs.
Benefits: Look at the benefits offered by the plan. Some may offer additional benefits that can be useful when you're out of state, like telehealth services.
Travel Habits: Reflect on your lifestyle and travel habits. If you frequently travel or live part of the year in a different state, a plan with broader coverage may be beneficial.
Finding a plan with out-of-state or nationwide coverage can be achieved in several ways:
Before you sign up for a plan, it's essential to fully understand its terms and conditions. Make sure you read all the material provided by the plan, paying close attention to the sections on out-of-state coverage, network restrictions, and costs for out-of-network services.
If anything is unclear, don't hesitate to contact the plan provider for clarification. It's important that you're fully informed before making a decision, as switching plans after the Annual Enrollment Period can be difficult and may come with restrictions.
Tips for Traveling Out of State with a Medicare Advantage Plan
When you're traveling out of state with a Medicare Advantage Plan, it's crucial to have ready access to healthcare services. Here are some steps to ensure this:
Know Your Network: Before you travel, research the healthcare providers in your destination that are part of your plan's network.
Telehealth Services: Check if your plan offers telehealth services. This feature could be very handy for non-emergency situations while you're on the move.
Prescription Medications: Ensure you have enough prescription medications for the duration of your trip. Alternatively, find out if your plan covers prescriptions at pharmacies out of state.
In case of an emergency, knowing the right steps to take is vital:
Emergency Services: Remember that in an emergency, go to the nearest emergency room. Medicare Advantage Plans are required to cover out-of-network emergency care.
Notify Your Plan: Once you're safe and stable, inform your plan about the emergency as soon as possible. They can provide guidance on next steps and procedures to follow.
Follow-up Care: If you require follow-up care, contact your plan to find out how to proceed, especially if you're still out of state.
Traveling with the right documents and numbers is important for a smooth healthcare experience:
Insurance Information: Carry your Medicare Advantage Plan card with you at all times. This will have crucial information for healthcare providers.
Emergency Contact Numbers: Keep a list of important numbers, including your primary care doctor, specialists, and the customer service number of your plan.
Health Records: Consider carrying a copy of your medical records, particularly if you have a complicated medical history or multiple prescriptions.
Travel Confirmation: If your plan offers out-of-state or nationwide coverage, bring a copy of the confirmation or the terms stating this, as some providers may not be familiar with your plan.
With these tips, you can travel confidently, knowing you're prepared for any health-related eventuality that might arise on your journey.
In this post, we delved into the complexities of using a Medicare Advantage Plan out of state. We established that while these plans often come with geographical restrictions, there are exceptions, particularly in the case of emergencies, urgent care, and dialysis. We also highlighted the types of Medicare Advantage Plans and the significance of understanding the network restrictions and coverage rules of your specific plan. Moreover, we discussed how to choose a plan with out-of-state or nationwide coverage, keeping in mind factors like your travel habits, costs, and benefits.
Contact your plan provider, ask questions, and ensure you have all the information you need to prevent unexpected expenses and to keep you healthy while you're away from home.
Choosing a Medicare Advantage Plan that fits your lifestyle and healthcare needs can seem daunting, especially if you frequently travel out of state. You're not alone in this. Should you have more questions or need further assistance, call a Fair Square Medicare expert at 888-376-2028. Enjoy your travels knowing that your health is well taken care of, no matter where you are.
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