understanding your medical insurance policy

Understanding Medicare Supplement Networks

by Peppi Halko

Open enrollment is the perfect time to change your Medicare supplement plan to a different company. While numerous programs are available in your state, they are not equal regarding accessibility. When comparing plans, you need to look at which doctors are in-network and which are not. But precisely what is a network, and why does this matter? Read on for more information. 

What Is A Provider Network?

A provider network is a group of health care providers within a geographical area with whom the plan has contracted to provide services to enrollees. Most Medicare supplement plans belong to a network, but some are more restrictive than others. A few of the network plans you may see include the following:

  • Health Maintenance Organization (HMO)
  • Special Needs Plan (SNP)
  • Preferred Provider Organization (PPO)
  • Private Fee-for-Service (PFFS)

Most networks require you to receive your care from their network providers, except for emergency care, urgent care, or out-of-area dialysis. 

How Do The Networks Vary?

Each network plan has different requirements for where you receive your care and how you access specialists and other services. Here is a brief outline of each of the networks.

Health Maintenance Organizations (HMO) Plans

HMO plans use a defined network of physicians, medical facilities, and hospitals that enrollees can choose from for their care. Primary care physicians must send you out for referrals.

HMOs usually offer the lowest out-of-pocket co-pays. Unfortunately, if you choose to receive your non-emergency health care services from a provider that is not within the network, you usually will not have insurance coverage. 

Preferred Provider Organization (PPO) Plans

PPO plans are very similar to HMOs as far as network providers but offer slightly more flexibility for receiving services from out-of-network providers. For the plan to pay for your out-of-network services, they must be reviewed and deemed medically necessary. Premiums for PPOs tend to be slightly higher in exchange for the plan's flexibility. 

Special Needs Plans (SNP)

SNP plans are Medicare Advantage plans designed and limited to people with specific diseases or conditions. Providers and drug formularies intended to address the illness or condition the plan targets usually are within the network.

Private Fee-for-Service (PFFS) Plans

PFFS plans offer you the advantage of receiving your services from any Medicare-approved doctor, hospital, or health care provider that accepts Medicare assignments. You can also receive benefits from out-of-network providers at a higher cost. Unfortunately, providers within must agree to the plan's terms and conditions and can opt out at any point. 

If you want to keep the same doctors, always do some research, ensure that your doctors are in-network, and accept the plan you choose. 

Contact a local Medicare service to learn more about Medicare supplement plans.