Welcome to Medicare school Daily where we help you understand Medicare, save money, avoid
mistakes, and above all get the most out of your Medicare benefits. Now one of the most
common concerns that people have as they go to Medicare is, "Can I go to any provider that
I'd like to?" In other words, can I go to any doctor, any specialist that I would like to? Well
maybe maybe not. It actually just depends on the insurance option that you select when
you start taking your Medicare benefits. Now may I remind you there's only two options
when you go on Medicare. One option is to stay in what we call the original Medicare
system. That's Medicare A and B you enroll in that and that means Medicare is the first
payer. Well there's some gaps in original Medicare so those are filled in by supplemental
plans. There's 10 different supplemental plans most people today are getting an F, G, or an
N plan. All right. And so this is one insurance option. The second option is to enroll in a
Medicare A and B but then you get what's called the replacement plan or an Advantage plan.
These are also called C plans. When I go this direction I don't use original Medicare any
longer I'm going to use a private health insurance company and say that they've actually replaced
my original Medicare benefits. So these are two options and depending upon which way you
go will determine the answer to that question because if I stay in original Medicare with
the supplemental plan, I can go to any provider that I want to. Any doctor, any specials, any
hospital as long as they take medicare I can go anywhere that I would like in this particular
system. If I go over here,
Such is not the case because now what we have is we have networks Medicare Advantage plans
always have networks and so we have to go to providers that are going to be within the
network. Now that still gives us plenty of options but now we have some restrictions
because now we're in a network plan. And so what we do next is I want to spend some time
explaining how these networks work within the Medicare advantage system. Now we have
two different networks within all advantage plans. One will be what we call HMO. Those
are health maintenance organizations and one PPO which are called preferred provider
organizations and these are going to be the only two options that we have. And so these
are different and so there's four different features of these and I want you to be clear
on if you decide to take an advanced plan. Number one the size of the network. We described
the HMO with the smaller box PPO much larger box. Well, why is that? Because in an HMO you're
always going to have less choices. Now that doesn't mean to say you don't have lots of
choices but you're going to have less choices in the HMO than you're going to on the PPO.
Why is that. Well because the providers that are within these networks if they're on an
HMO that provider gets less money as a reimbursement rate than they do on the PPO. Now where as the
PPO plans pay the doctors and the specials and the hospitals more reimbursement money.
And so there are some doctors who say I'm not going to see patients for that little money.
I like the PPO contract, it pays us more and they're willing to go in that particular
network. So it's very simple. That's why there's a difference in the size of the network. Now
there are a lot of people that either aren't on HMO because what happens even though they
have less choices with the HMO is will often do is they will give you lower co-pays. They
will also give you lower max out of pockets. So they sometimes can beef up the financial
side of this because instead of having a larger network, this may be a little bit
better financially for you. So the PPO those are much larger we have more choices for sure
but that's the difference of the size of the network. The second thing would be referrals.
Now on a referral what that means is you're wanting to see your cardiologist or maybe
a dermatologist or a rheumatologist or something. Some HMO plans require that you see your primary
care doctor first and then they will make the referral for you to see the specialist.
Now not all HMO do that, but some do.
And so that's a restriction that you have to find out if your HMO requires that. If you're
on a PPO Advantage plan, they never require a referral if you want to go see your cardiologist,
your dermatologist, your rheumatologist just whoever you want to see pick up the phone, Give them
a call, make an appointment. You don't have to worry about it at all because there's no referral
required on PPO plans. So again that's a network difference. And then thirdly out of network
benefits and that's what this OON stands for. On an HMO plan, you do not have the right
to go out of network. You cannot go out of network. You must stay in your network of
providers. All right? PPO is not that way. On a PPO plan, if you're enrolled in one, all you
have to do is go out of network, call them up, and go out. Any provider that takes
Medicare you have the right to do that. Now the way it works is this. If I'm on a PPO
plan if I stay within my network, my annual max out of pocket, we'll just call it $5,000.
That's the most I have to spend the whole year. If I go out of network,
that's going to change, it may bump up to maybe $7,000 a year. So I do have
the privilege to go out of network, but it just may cost me a little bit more money.
But all PPO's allow you to go to any provider that you would like to out of the network.
You just have to pay a little bit more for that. HMO's, we must stay in our network. Now
the exception to that is this - Urgent care and emergency. If you're on an advantage plan
and you find yourself needing to go to urgent care or maybe some kind of a minute clinic
a quick clinic or maybe the emergency room at a hospital. This is one place where you
have no network whether you're on an HMO or a PPO you can go any into any urgent care
or any emergency room actually anywhere in the world. You never have to worry about your
network. And that just makes common sense because of all the advantage plan and I'm
having a heart attack. The last thing these networks want me to worry about is the hospital
on my network or is this doctor that's going to treat me in the emergency room. Are they
in the network. No one should do that. Then we should go get the proper care. And you
worry nothing about network when it comes to urgent care or emergency room. But beyond
that we have to live within the rules of the network. So back to our question. If you're
going on Medicare can you go to any doctor. Well you can go to any doctor that takes Medicare
if you stay in original Medicare with the supplemental plan. If You don't then you're
going to have some network restrictions. If you decide to take an advanced plan. So, hope
that helps you to understand all about the providers and all about the advantage plan
networks. Thanks so much for watching.