Medicare Advantage, also known as Medicare Part C, is an excellent healthcare solution for many people. The coverage is extensive, and it often has lower costs than original Medicare. However, there are challenges for people using this type of healthcare insurance. One of the primary issues is finding in-network providers. Many insurance providers use networks of providers to keep costs down and using out-of-network providers often incurs larger out-of-pocket costs through higher co-pays. Co-payments for out-of-network physicians may also increase your yearly maximum out-of-pocket limit. Finding a primary doctor who accepts your Medicare Advantage plan is essential for keeping your costs down. This guide offers tips for finding a quality physician who accepts Medicare Advantage and is within your network.

The Basics of Medicare Advantage

Medicare Advantage is available to people eligible for Medicare Part A and B. It provides the same insurance coverage as Part A and B, namely hospital and medical, but providers can also offer additional coverage such as vision and dental care. Medicare Advantage plans often include Medicare Part D, or prescription medicine, as an integrated part of the plan as well.

Under the system, the government pays private health providers a set amount each month for your care. There are many variables that determine how much you pay for your Medicare Advantage plan, including how healthy you are, the cost of co-payments and whether you use in-network physicians. The use of networks allows health insurance providers to offer lower costs to people using Medicare Advantage than those on original Medicare, as physicians in the network agree to charge discounted prices. These discounts are passed on to clients through smaller co-pays and out-of-pocket expenses spending limit each year.

Tip 1 – Ask Your Current Doctor

If you’re happy with your current primary care doctor, you may wish to stay with them. Keeping your current doctor means your healthcare stays consistent and you’re not faced with the task of finding a new healthcare provider. If you’ve just become eligible for Medicare and are deciding on a Medicare Advantage plan, ask your doctor’s office which provider network they belong to. With this information, you may be able to choose a plan that lets you stay with your current doctor.

Tip 2 – Get Recommendations

Some people may not have a primary care physician or may need to find a new one due to the Medicare Advantage plan they choose. If this is you, it can be helpful to start by asking friends and family for recommendations. It’s important to find a doctor you feel comfortable with and who provides high-quality service. With recommendations from people you trust, you can have a list of doctors who are likely to fit that bill. From here, it is a matter of finding out if they are in your network.

Tip 3 – Review Your Plan

Your health insurance provider will have information about the physicians that are in their network. The easiest way to find this information is on the health insurance provider’s website. Most providers have a search function that allows you to find all the primary care doctors in your area. These websites often list additional information, such as quality ratings. If you’re more comfortable talking to someone, you can contact the provider on the phone. Their staff should be able to give you a list of the doctors that are close to you.

Tip 4 – Do a Quality Check

If you have a list of primary care doctors that may be able to help you, it’s time to do a quality check. A google search can often provide information about the physicians you’re considering, although it’s good to look at trusted sources. The Physician Compare tool is available on the Medicare website. This shows performance information scores for doctors around the country. Patient survey results are also available for selected physicians. Certification Matters is a website from the American Board of Medical Specialties, which shows whether the doctor you’re considering is board certified. DocInfo, from the Federation of State Medical Boards, also has information on the licensing and background information of the nation’s doctors.

Tip 5 – Call the Doctor

Lastly, call the office of the doctor you’re considering. There are basic questions that they can answer for you, including which network they’re in and whether they’re accepting new patients. How the office staff answer the call can also give you an impression of the practice and whether they’re efficient and friendly. You can also ask how long it takes to get in and see the doctor, if the office is easy to get to and if they process insurance claims.

Frequently Asked Questions

What is a primary care physician?
A primary care physician is a doctor who provides basic medical care for a client. They are the first point of contact for undiagnosed health issues. They often diagnose and treat common illnesses and conditions and refer patients to specialists or for further tests if they’re unable to find the cause or provide treatment. Primary care physicians also educate people regarding healthy behaviors and lifestyle changes that can improve health.

What are the benefits of a primary care physician?
Primary care doctors are your first point of contact for health problems and over time they learn your medical history, reactions to medication, lifestyle and treatment preferences. With that background information, they’re able to pick up on the changes that indicate ill health which may help diagnose problems in their early stages. Many Medicare Advantage plans, especially those from HMOs, require you to have a primary care physician to coordinate your health care.

Do I need a primary care doctor on Medicare Advantage?
Whether or not you need a primary care physician depends on your plan. Plans provided by health management organizations (HMO) almost always require a doctor that coordinates your care. These plans also require a referral to cover an appointment with a specialist and primary care doctors can provide these referrals. People with special needs plans also need a primary care doctor. However, you don’t need to choose a primary care provider if you have a preferred provider organization (PPO) plan or a private fee-for-service (PFFS) plan.

What is a network and which types of plans use one?
Provider networks are groups of healthcare providers that contract with health insurance carriers to provide low cost healthcare and accept the discounted price as payment in full. They include a full range of healthcare providers, including primary care doctors, specialists, testing facilities and home healthcare companies. Insurance providers use networks to keep costs down, as the physicians have agreed to charge lower prices. In return, physicians in the network get a large volume of clients by being part of the network. HMOs use networks and keep costs down for people on their plans by restricting members to physicians in their networks. Although PPOs also use networks, they often allow you to use out-of-network healthcare providers for a higher copayment.

What happens when I change primary care doctors?
If you’re on a Medicare Advantage plan and wish to change primary care physicians, make sure you check with your plan first. For HMO plans, your new doctor will need to be part of the network and you are required to notify them of a change in primary care doctor. After receiving your notification, your health insurance provider will send out a new ID card with the doctor’s information printed on the back. Make sure your new physician accepts your health insurance and is accepting new patients before calling your health insurance provider. PPO plans don’t require notification of a change of primary care physician.