Mistake #9: Going Out-of-Network in Your Medicare Advantage Plan

by David Bynon, last updated

In Medicare Mistake #8 we explained the importance of understanding your coverage and reviewing it annually. In this installment of our Medicare Mistakes Series, we want to explain how costly it can be to go out of network in most Medicare Advantage plans, and what you can do about it.

Key Takeaways

  • All Medicare Advantage plans have an in-network out-of-pocket maximum. This is the most you will pay out-of-pocket for Medicare Part A and Medicare Part B services when you use in-network providers.
  • Plans also have a combined in-network and out-of-network maximum.
  • In 2021, the combined maximum increased to $11,300 (previously $10,000). Plans can set their limit lower, but not higher.
  •  The maximum out-of-pocket (MOOP) limit is only for health care services. It does not include your Medicare Advantage plan’s prescription drug coverage or other extras, like dental and vision.
  • You must continue to pay your plan’s monthly and Medicare Part B premiums if you reach your plan’s MOOP limit.

Let’s say you join a Medicare Advantage HMO plan but later learn your favorite doctor is not in the plan’s network.  Can you continue to see your physician? The short answer is yes, but you will pay 100 percent of the costs yourself.

The cost of receiving Medicare Part A and Part B services out-of-network contributes to your plan’s out-of-network spending limit. These costs can add up quickly. A typical doctor visit might only run a couple of hundred dollars, but specialists, diagnostic tests, and durable medical equipment can quickly run your bill up into the thousands.1Medicare.gov, ”Doctors, providers & hospitals in Medicare Advantage Plans”, Accessed January 15, 2022

NOTE: Original Medicare and Medigap do not use provider networks. With Original Medicare and Medicare supplement insurance, you can use any healthcare provider that accepts Medicare-assignment (Medicare’s payment terms).1Medicare.gov, ”Doctors, providers & hospitals in Medicare Advantage Plans”, Accessed January 15, 2022

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Evidence of Coverage and Annual Notice of Change

Each year your Medicare Advantage plan will send you an Evidence of Coverage (EOC) document. The document will include clear language that explains what you will have to pay out-of-pocket for both in-network and out-of-network services. The EOC will also tell you what your combined maximum out-of-pocket limit is. This is important information.2Medicare.gov, ”Evidence of Coverage (EOC)”, Accessed January 15, 2022

Plans can change their MOOP limits for in-network and out-of-network Part A and Part B coverage every year. The higher the MOOP, the more you will pay out of your own wallet before costs are covered 100% by your plan.  Medicare adjusts the maximum MOOP limit for all Medicare Advantage plans annually.3Medicare.gov, ”Things to know about Medicare Advantage Plans”, Accessed January 15, 2022 That’s why it’s important to pay attention to your plan’s Annual Notice of Change (ANOC) letter. The ANOC will notify you about upcoming changes to your MOOP and other costs.4Medicare.gov, ”Plan Annual Notice of Change (ANOC)”, Accessed January 15, 2022

Switching Medicare Advantage Plans Mid Year If Needed

If you joined a Medicare Advantage plan during the Annual Election Period (AEP) in the Fall, and then discover that your preferred provider is not in your plan’s network, you can relax, because you get a second chance.

The Medicare Advantage program has a second enrollment period that starts January 1 and ends March 31. During the Medicare Advantage Open Enrollment Period (MA-OEP), you can change plans or disenroll from a plan and go back to Original Medicare. Changes you make will go into effect on the first day of the month after you make the change.5Medicare.gov, ”Joining a health or drug plan”, Accessed January 15, 2022

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You may also make changes to your Medicare Advantage plan due to certain life events. Some qualifying events include:6Medicare.gov, ”Special circumstances (Special Enrollment Periods)”, Accessed January 15, 2022

  • Moving out of your plan’s area.
  • Moving to a new address that’s in your plan’s service area, but new plan options are available.
  • Moving back to the USA after living outside the country.
  • Losing Medicaid or employer-based coverage.

In these and a few other situations, Medicare will give you a Special Enrollment Period (SEP), allowing you to switch plans or enroll mid-year.  Generally, a SEP gives you two full months to enroll in a new plan. If you don’t enroll in a new plan, you will be automatically dropped from your current plan and re-enrolled back in Original Medicare.6Medicare.gov, ”Special circumstances (Special Enrollment Periods)”, Accessed January 15, 2022

Medicare Gives You Plenty of Opportunities

If you found yourself in the wrong plan, you don’t have to suffer with it, but you do need to act. Going out-of-network to get the care you need is always the most expensive option. As soon as you realize the plan you’re in was a mistake, it’s time to act.

In addition to the MA-OEP and SEP opportunities, Medicare Advantage has a 5-star plan enrollment period. This allows you to change to any 5-star plan once from December 8 through November 30.7Medicare.gov, ”5-star special enrollment period”, Accessed January 15, 2022

Call 1-855-728-0510 (TTY 711) for plan assistance.

If you qualify for Medicare and don't know where to start, MedicareEnrollment.com, an independent HealthCompare insurance broker, has licensed insurance agents who can help you with your Medicare enrollment options, Mon-Fri, 8am-9pm , SAT 8am-8pm EST.


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