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

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 plansMedicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare (Medicare Part A and Medicare Part B)., and what you can do about it.

Let’s say you join a Medicare Advantage HMO plan but then 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 equipmentDurable medical equipment (DME) is equipment that is designed to last and can be used repeatedly. It is suitable for home use and includes wheelchairs, oxygen equipment, and hospital beds. can quickly run your bill up into the thousands.¹Medicare.gov, ”Doctors, providers & hospitals in Medicare Advantage Plans”, Accessed January 15, 2022

NOTE: Original MedicareOriginal Medicare is private fee-for-service health insurance for people on Medicare. It has two parts. Part A is hospital coverage. Part B is medical coverage. and Medigap do not use provider networks. With Original Medicare and Medicare supplement insuranceMedicare Supplements are additional insurance policies that Medicare beneficiaries can purchase to cover the gaps in their Original Medicare (Medicare Part A and Medicare Part B) health insurance coverage., 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

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 ChangeAn Annual Notice of Change (ANOC) is an official notice sent by Medicare Advantage and Medicare Part D plans to their members in late September. The notice provides a summary of the changes to coverages... (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 PeriodDuring the Medicare Open Enrollment Period, Medicare Advantage and Part D plan members can change, switch, or drop a plan they chose during the Annual Election Period. OEP starts on January 1 and ends on March 31. (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

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 MedicaidMedicaid is a public health insurance program that provides health care coverage to low-income families and individuals in the United States. or employer-based coverage.

In these and a few other situations, Medicare will give you a Special Enrollment PeriodSpecial Enrollment Periods (SEPs) allow beneficiaries to change their Medicare Advantage and Part D plans due to a special circumstance. Common reasons for a SEP include moving, losing employer coverage, and Medicaid eligibility, to name... (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

Citations

• 1
  Medicare.gov, ”Doctors, providers & hospitals in Medicare Advantage Plans”, Accessed January 15, 2022
• 2
  Medicare.gov, ”Evidence of Coverage (EOC)”, Accessed January 15, 2022
• 3
  Medicare.gov, ”Things to know about Medicare Advantage Plans”, Accessed January 15, 2022
• 4
  Medicare.gov, ”Plan Annual Notice of Change (ANOC)”, Accessed January 15, 2022
• 5
  Medicare.gov, ”Joining a health or drug plan”, Accessed January 15, 2022
• 6
  Medicare.gov, ”Special circumstances (Special Enrollment Periods)”, Accessed January 15, 2022
• 7
  Medicare.gov, ”5-star special enrollment period”, Accessed January 15, 2022