What is the difference between a doctor accepting Medicare and being in-network for a plan?
The short answer
A doctor who accepts Medicare has agreed to bill Medicare for covered services. Being in-network for a Medicare Advantage plan means that doctor has a separate contract with your specific private plan, which affects your costs and whether the plan will cover the visit at all.
The full explanation
This distinction trips up a lot of people, and it matters quite a bit depending on which type of Medicare coverage you have.With Original Medicare, the key question is simply whether a doctor accepts Medicare assignment. If they do, Medicare pays its share and you pay yours, typically 20 percent after your deductible. You can see that doctor no matter where you live or which state you are in.With Medicare Advantage, accepting Medicare is not enough on its own. Your private plan has its own separate network of doctors and facilities. A physician can accept Medicare perfectly well but have no contract with your specific Advantage plan. If you see that doctor, you may pay significantly more, or the visit may not be covered at all depending on the type of plan you have. HMO plans in particular often pay nothing for out-of-network care except in emergencies.This is one of the most important things to check before enrolling in a Medicare Advantage plan. Do not assume your current doctors are in-network just because they take Medicare. Call the doctor's office directly, and also check the plan's online provider directory, since directories can sometimes be out of date. Verifying network status before you enroll can save you from a costly surprise later.
Related Medicare Resources
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In Utah, many Medicare Advantage plans are built around either Intermountain Health or University of Utah Health. If your doctor is affiliated with one system but your plan is built around the other, you could find yourself out of network even though your doctor absolutely accepts Medicare.
What this means for you
For you, this means before joining any Medicare Advantage plan, you should confirm your specific doctors are in-network with that specific plan, not just that they accept Medicare in general.
Related Questions
Do all doctors accept Medicare?
How do I check whether my doctor accepts Medicare and is in-network?
Do Medicare Advantage plans limit which doctors I can see?
Can I see any doctor or specialist with Original Medicare plus a Medigap plan?
