What's the key difference in how Medicare Advantage and Medigap handle out-of-network providers?

Question

Comfort Olude · Accepted Answer

Medicare Advantage plans typically require that you stay and get your healthcare within a network of providers, and it has a potentially higher cost for out-of-network care. Meanwhile, with Medigap, you can see any doctor or hospital that accepts Medicare.

Answered by Comfort Olude on March 30, 2025

Broker Licensed in CA, FL, GA & 9 other states

Answered by Comfort Olude Medicare Insurance Agent

Brian Moore · Answer

Medicare Advantage often ties you to a network—go out-of-network, and you’re either paying more or not covered at all, unless it’s an emergency, which I’ve seen trip up clients who didn’t check their plan’s rules. Medigap, paired with Original Medicare, doesn’t care about networks; any provider accepting Medicare works, giving you flexibility I’ve found folks appreciate when they travel or need specialists. It’s a clear-cut distinction that hits home when you’re picking between the two.

Answered by Brian Moore on March 26, 2025

Broker Licensed in OH

Answered by Brian Moore Medicare Insurance Agent

Misty Bolt · Answer

This answer is provided in a video format. Watch the agent's video response here: https://medicareagentshub.com/questions/whats-the-key-difference-in-how-medicare-advantage-and-medigap-handle-out-of-network-providers#misty-bolt

Joseph Bachmeier · Answer

If you have a Medicare Advantage HMO plan, then you need to use the doctors in the Network. If you have a PPO plan, you can use Medicare doctors outside the network, but you can expect to pay 40% out of pocket costs for services. If you have a Medigap plan, Original Medicare is your primary insurance. With Original Medicare you can use any doctor or hospital in the United States who accepts Medicare.

Answered by Joseph Bachmeier on April 7, 2025

Agent Licensed in PA, AZ, DE & 5 other states

Answered by Joseph Bachmeier Medicare Insurance Agent

William Gray · Answer

Originial Medicare does not have a Network, you can use your red white and blue Medicare card at any Dr. or Hospital that accepts Medicare. 

Medicare Advantage replaces Originial Medicare and has in most cases a network of Dr. and Hospitals that you must use to ge the best rates avaialble.

Robert Pennington · Answer

A Medigap Plan has no net work and allows you to go to any Provider that accepts Medicare. A Medicare Advantage PPO Plan allows you to see a Provider in or out of network. A Medicare HMO Plan is in net work only.

Answered by Robert Pennington on May 28, 2025

Broker Licensed in NC, GA, SC & VA

Answered by Robert Pennington Medicare Insurance Agent

William Kravit · Answer

Their are no networks with original Medicare, whereas Advantage plans have in-network and out of network providers. Under an Advantage plan, if the provider agrees to treat you, there is usually a bigger maximum out of pocket (moop). So if the provider accepts the Advantage plan, there should be no difference in medical services, just in how it's paid. With a Medigap, th eout of pockets are very limited, and with an Advantage plan the out of pocket can be significant like $8000 or thereabouts.

Answered by William Kravit on March 25, 2025

Agent Licensed in WI, AZ, CO & 9 other states

Answered by William Kravit Medicare Insurance Agent

Nolan Popel · Answer

Medicare supplement plans don’t have doctor networks. Someone with a Medicare supplement plan would have original Medicare as their primary. When that person chose a Medicare advantage plan as long as it is a PPO then they would be able to go out of network as long as the doctor did accept Medicare.

Answered by Nolan Popel on April 28, 2025

Agent Licensed in NY, AZ, CA & 15 other states

Answered by Nolan Popel Medicare Insurance Agent

Steven Bleicher · Answer

By definition, a Medigap (aka, Med. Supplement) is a totally Non-network program. As long as you verify that the doctor whom you are about to visit for the first time accepts Medicare for his being reimbursed, there's no worry whatsoever, anywhere in the US. 

However, that being said: If you have enrolled with a "concierge doctor" who despises the paperwork that Medicare imposes upon all doctors, she/he may NOT accept any Medicare patient, at their discretion. The truth is that this type of doctor just does not want to hire a big staff which will adversely affect his/her profit margins. 

In contrast, a Med. Advantage plan can be an HMO (a definite In-Network plan only) or a PPO (this is called a Preferred Provider Organization, with the chance to visit an In-Network as well as an Out-of-Network doctor, at your convenience). Though the copays with the out of network doctors will be a greater $$ copay amount than with an In-Network PPO practice.

Timothy Brown · Answer

There’s no such thing as an out of network providers with Medigap plans because Original Medicare (Part A & B) is your primary insurance/coverage which means that if your doctor or hospital accepts Medicare the Medigap plan, by default, is also accepted. In fact, the Medigap plan’s function is to cover the approved medical excess charges that are not covered by Original Medicare.

Answered by Timothy Brown on May 1, 2025

Broker Licensed in PA, CT, DE & 15 other states

Answered by Timothy Brown Medicare Insurance Agent

Chad Watkins · Answer

This answer is provided in a video format. Watch the agent's video response here: https://medicareagentshub.com/questions/whats-the-key-difference-in-how-medicare-advantage-and-medigap-handle-out-of-network-providers#chad-watkins

James Schneider · Answer

There is no network of doctors with Medigap plans. As long as the facility and or doctor accept original Medicare then the Medigap pays after Medicare. Medicare advantage are managed care plans and have a network of providers to help manage cost and then may offer to provide some additional benefits

Answered by James Schneider on March 31, 2025

Broker Licensed in OH, FL & MI

Answered by James Schneider Medicare Insurance Agent

Fred Manas · Answer

The main difference is that Medicare Advantage plans generally require you to stay within their network of providers, while Medigap plans allow you to see any doctor or specialist who accepts Medicare, regardless of whether they are in-network or out-of-network. 
Elaboration:
Medicare Advantage:
.
These plans are offered by private insurance companies and often have specific provider networks. While some plans may offer some level of coverage for out-of-network care, it's usually less comprehensive and may involve higher costs. 
Medigap:
.
Medigap plans are supplemental insurance that works with Original Medicare. They cover the costs that Original Medicare doesn't, such as co-pays, coinsurance, and deductibles. A key advantage of Medigap is that you can use any doctor or hospital that accepts Medicare, regardless of whether they are in-network or not.

Gary Henderson · Answer

Medicap really has an auto network provider because they don't care what the insurance is. It's whether the doctor takes original Medicare or not. Whatever the medigap plan and doesn't matter they have to take it so it is extremely difficult to be out of network with medigap plans 
On the other hand, Medicare advantage plans work exactly like your corporate plan did when you were working and you have to stay in network dentist. If you go out of network, you get charged additional monies. If it's a PPO or POS plan HMO plans, you must stay in network or you don't have any other coverage

Vachik Chakhbazian · Answer

The main difference is that Medigap (Medicare Supplement) plans allow you to see any doctor or specialist who accepts Medicare, regardless of whether they're in-network or out-of-network. Medicare Advantage plans generally require you to stay within a network of providers, and may charge more or not cover services if you go out-of-network.

Answered by Vachik Chakhbazian on May 25, 2025

Agent Licensed in CA, AL, AR & 22 other states

Answered by Vachik Chakhbazian Medicare Insurance Agent

Carol Thompson · Answer

Medicare Advantage has a provider network where it may be not cover out of network charges or if out of network there may be a higher charge. 

Medigap or AKA - Medicare supplement allows you to see any Dr or go to any hospital as long as they accept Medicare. Regardless on whether you are in or out of network.

Mary Salmon · Answer

This is one of the biggest differences between Advantage plans and Medigap plans. With Original Medicare & a Medicare Supplement (medigap plan), there are no networks. Beneficiaries can go to any doctor or provider anywhere in the US without a referral as long as the provider accepts Medicare. With an Advantage plan, you must stay in-network to get the most benefit out of your plan. Going to an out-of-network provider will increase the out of pocket expenses and cost much more than staying in-network.

Answered by Mary Salmon on May 29, 2025

Broker Licensed in TX & OK

Answered by Mary Salmon Medicare Insurance Agent

Gary Haft · Answer

Medigap or Medicare Supplements do not have provider networks and therefore you can see any provider of your choice. Medicare Advantage Plans all have provider networks. HMO Plans you must use only "In-Network" providers and PPO's allow you to go out of network, but you must ask that provider if they will accept the "terms, Conditions & Fees" associated with your Medicare Advantage Plan. Out of network providers are not mandated to care for you and could ask you to pay out of pocket.. Most of the time if they are not on the plans network, they will not necessarily work with you.

Answered by Gary Haft on May 26, 2025

Agent Licensed in FL, AL, DC & 9 other states

Answered by Gary Haft Medicare Insurance Agent

Eizel Mere · Answer

Medicare advantage HMO plans you need a referal to see doctors, PPO plans ypu do not need referals but a doctor can tell you they dont take your plan. A Medicare supplement plan if the doctor take original Medicare they take your plan it does not matter the company.
The Medigap are plans used to fill the gaps of Medicare. Expensive copays like ER, ambulance and hospital. These plans do not pay your medical provider they pay you directly.

Ron Gambles · Answer

Medicare Advantage Plans are "Coordinated Care Plans" where as, Supplement Plans are not.  What that breaks down to is that the Advantage Plan Provider and willing Physicians agree to provide care in agreed process in a variety of different formats.  For example, an HMO, PPO or PFFS.  These all have particular guidelines that must be followed in the healthcare process.

On the other hand, Med Sup Plans do not function this way.  There are no "Coordinated Care" formats to adhere to, a beneficiary is free to see any physician that accepts Medicare and most do.

So, this is a very basic distinction between the two.  Both have "pros and cons", it really means that you should get an accurate understanding of how each work.  Then you will have to decide which will work best for you.

Judi Norton · Answer

Medicare Advantage plans all contract with certain pharmacies, clinics and hospitals for the services; in-network and out-of-network copays. Any doctor that takes Medicare or Medigap (Medicare Supplements) does not have out-of-network. Medicare is your primary, it therefore is billed first and the remainder of the charges through Medicare are billed to the Medigap Plan.

Answered by Judi Norton on April 14, 2025

Agent Licensed in NM

Answered by Judi Norton Medicare Insurance Agent

Gene Page · Answer

With Medigap, there is not a network, except in certain discount products which are specifically defined as such, generally tied to a hospital network, not doctors or clinics. 
Medicare Advantage has different levels of product: HMO, PPO, etc. where you must follow their rules in order to access coverage, except in emergency situations.

Stella Hattox · Answer

Advantage if PPO plan - It normally has higher co pays or higher out of pocket.

Medigap works with Medicare, if provider is not Participating with Medicare,  patient may be liable for all charges or higher out of pocket. If Medicare does not cover it-Medigap will not cover it.

What's the key difference in how Medicare Advantage and Medigap handle out-of-network providers?

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What's the key difference in how Medicare Advantage and Medigap handle out-of-network providers?

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