What should I do if I find out that my preferred hospital isn't in-network with my Medicare Advantage plan?
Answered by 20 licensed agents
You can go to any doctor or hospital with Medicare Advantage. Although, there have been instances where a hospital drops the Medicare Advantage plan. You can switch plans during Medicare Advantage open enrollment, Jan 1 to March 31. If you can't find another plan to switch to, you could return to Original Medicare and you could also pair Original Medicare with Medigap.
If a member likes their plan, they can find out where else they can go for services, they also can change their plan, and possibly get an exception to go to their hospital
If your preferred hospital isn’t in-network with your Medicare Advantage plan, it’s a significant issue—over 25 years, I’ve found most people won’t abandon the trust they’ve built with their doctors and hospitals due to insurance limitations, making it essential to work with a professional to confirm network coverage upfront. You can switch plans during the Annual Enrollment Period (October 15 to December 7) or the Medicare Advantage Open Enrollment (January 1 to March 31) to align with your hospital, and with today’s wide range of competitive plans, we can typically find one that includes your providers without much trouble. If you’re caught mid-year, a Special Enrollment Period might apply—like after a move or loss of other coverage—or you’ll face higher out-of-network costs, which vary by plan and can add up quickly.
That is something you want your Medicare agent to advise you on. In some cases, you may fall into a Special Election Period. But for the most part before you purchase an Advantage Plan you will want your broker to check the network for your hospital and doctors.
Ask them to get in-network, find out what your out of network charges will be compared to in network charges, negotiate with the hospital for a cash price, enroll into a different plan that is in network when you are able to do so.
Call your trusted Medicare plan advisor. There are special election periods (SEPs) throughout the year that might offer a chance to change plans, during the year if needed, so you can have access to the hospitals and providers you prefer. Your advisor should have knowledge of what SEPs are available to you.
You should not have a Medicare Advantage Plan that does not include your local or favorite hospital. Before you join a Medicare Advantage plan you or your agent should always check to be sure your doctors, hospital and all of your prescriptions are covered in your Advantage plan. If your hospital is not in your Advantage plans network, the needs analysis was not performed or not mentioned before enrolling. This should not happen. You are obligated to stay in the plan you pick until AEP Annual Enrollment Period which is from October 15th to December 7th each year. This date is when you make a change to a plan that has all of your doctors' hospitals and prescriptions covered. The plan you change to will be effective the 1st of January in the following year. There are many more scenarios that are not mentioned here but this is most common question and answer. For more info call or email 888 589 4403 or [email protected]
During the next Annual Open Enrollment period in the fall (October 15th through December 7th) for an effective date of January 1st of the next year, you have the right to switch to another company's Advantage plan which now includes your favorite hospital. BUT be aware that in the process, you could lose a favorite doctor or two who might be a part of your current network! It sounds likely that if you used an agent to “show you the ropes” of Medicare, that she/he failed to check on the doctors AND the hospital that you preferred! So, if I were you, I’d consider changing agents!
First check to see if another Medicare Advantage Plan works and is accepted by that Hospital. Also consider looking at a Hospital Indemnity Plan to go with your Advantage Plan.
Also determine what the out-of-network costs would be to keep your Plan and understand the cost risk to stay with that Hospital or review Hospitals that do accept your current Plan.
If you discover that your preferred hospital isn’t in-network with your Medicare Advantage plan, here are some steps you can take:
Contact Your Plan: Reach out to your Medicare Advantage plan's customer service for clarification on your coverage options and whether any exceptions can be made.
Check for Out-of-Network Coverage: Find out if your plan covers out-of-network services and what the associated costs would be.
Explore In-Network Alternatives: Look for other hospitals or providers in your plan's network that can provide similar services.
Consider Plan Changes: If you're unhappy with your current plan, consider switching to another Medicare Advantage plan during the next open enrollment period that includes your preferred hospital.
Consult With a Medicare Advisor: If you're feeling overwhelmed, seeking assistance from a Medicare advisor or agent can help you understand your options and make informed decisions.
If you have a HMO (HMO has to stay in network vs. PPO can go outside network) you would want to figure out your next best choice as far as a hospital option.
Then when the next election period comes up you could look at plan options that would include a network with your preferred hospital. The Annual Election Period is every year from October 15 - December 7 ... that would allow a person to change plans if needed/wanted.
If your preferred hospital drops out of your Medicare Advantage network, you should consult with an independent agent to determine your options. You may have a special enrollment period if you have access to a five-star plan in your area. There may be other options available to you as well. Consult a local independent health agent to get your best option. It's a no-cost appointment for you.
Regrettably, you will have to use the hospital in their network or pay a higher out of pocket. Rather your plan is an HMO or a PPO, would determine the out of pocket cost. HMO's having a stricter network. During the annual AEP from October 15th through December 7th, you can review other plans to see if you can find a better fit for you that may include your hospital of choice.
If your preferred hospital isn't in-network, contact our consultants to explore other plan options or find a suitable alternative. We're here to help you navigate your choices.
this is concerning that you don't have your preferred hospital in the network. Are you on a Medicare Advantage PPO plan? This would still allow you to go to that hospital (although you may pay a higher co pay), If it is an emergency situation, your plan would still cover an out-of-network hospital.
If you do not have a PPO which may allow out of network coverage for your hospital, you would have to change hospitals. During annual enrollment October 15 - December 7th you could change plans to one where your hospital is in network.
I would definitely check the provider list to see what hospital is in the network for your plan. Remember you can make a change at AEP between 10-15 and 12-7 of every year with the effective date being January 1st of the following year.
Also during OEP, you make one change to a different plan between Jan 1 and March 31.
Hopefully, you are within the 12-month trial period for your Medicare Advantage plan that allows you to switch to a different plan that may work better for you. If not, you may have to wait until open enrollment, Jan. 1st-March 31st, to change plans if a special enrollment period is unavailable.
First, I always check doctors, hospitals and prescriptions for my clients.
But, if something changed network wise, if its is still during open enrollment, we can make a change. If not, we can schedule a meeting for the upcoming Annual Enrollment period.
We also have ancillary plans available year round that can help cover what the Medicare Advantage doesn't fully cover.
