What's the key difference in how Medicare Advantage and Medigap handle out-of-network providers?
Answered by 11 licensed agents
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.
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.
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.
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.
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.
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.
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
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
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.
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.
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.
