Original Medicare vs Medicare Advantage: How Your Choice Affects Which Doctors You Can See

Two ways to get Medicare

Medicare.gov describes two main ways to get your Medicare coverage. Original Medicare includes Part A (hospital insurance) and Part B (medical insurance); you can add a separate Part D drug plan and buy a Medigap policy to help with your share of costs. Medicare Advantage, also called Part C, is an alternative offered by private insurance companies that Medicare approves. These plans bundle Part A, Part B and usually Part D.

For most people the choice comes down to cost, extra benefits and doctors. This guide covers the doctor side: which clinicians you can see under each option, and how to check before you commit.

Original Medicare: any provider who takes Medicare

Medicare.gov's side-by-side comparison says that with Original Medicare you can use any doctor or hospital that takes Medicare, anywhere in the U.S. It also says that in most cases you do not need a referral to see a specialist, and in most cases you do not need prior authorization.

What "takes Medicare" means in practice

Under Original Medicare there is no network, but providers still relate to Medicare in different ways, and that affects what you pay. Medicare.gov's assignment page explains three situations:

• Accepts assignment: the provider agrees to the Medicare-approved amount as full payment and charges you only the deductible and coinsurance.
• Non-participating: the provider may accept assignment case by case. When they do not, they can in many cases charge up to 15% above the Medicare-approved amount, the limiting charge.
• Opted out: Medicare does not pay for their services, except in emergencies, and you pay under a private contract. CMS publishes a list of opt-out affidavits.

Our Medicare assignment guide explains these terms in more detail.

Costs to keep in mind

The same comparison notes that Original Medicare has no yearly limit on what you pay out of pocket unless you have supplemental coverage, and that you can choose to buy Medigap to help pay those costs.

Medicare Advantage: networks and plan rules

According to Medicare.gov's comparison, with Medicare Advantage you may need to use doctors and other providers who are in the plan's network, you may need a referral to see a specialist, and you may need prior authorization for certain services. Plans have a yearly limit on what you pay for covered Medicare services, and most include Part D drug coverage. The two most common plan types handle networks differently.

HMO plans

Medicare.gov's HMO page says that you generally must get care from doctors, other providers and hospitals in the plan's network, except for emergency care, out-of-area urgent care and temporary out-of-area dialysis. In most HMOs you need to choose a primary care doctor, and in most cases you need a referral to see a specialist. Certain services, like yearly screening mammograms, do not require a referral. If you get care outside the network, you may have to pay the full cost. Some HMOs are Point-of-Service (HMOPOS) plans that may let you get some services out of network for a higher copayment or coinsurance.

PPO plans

Medicare.gov's PPO page says that you pay less when you use providers in the plan's network, and you can generally go to out-of-network providers for covered services if they participate in Medicare or accept assignment, but you will usually pay more. You do not need to choose a primary care doctor, and you do not need a referral to see a specialist. Before you see an out-of-network provider, the page advises contacting the plan to make sure the services are medically necessary and covered. Emergency and urgent care are always covered.

When your doctor leaves a plan

Networks can change during the year. The HMO page says that if your doctor or other provider leaves the plan, the plan will notify you and you may choose another provider in the plan. It also says that if you switch plans while you are getting a treatment, you have at least 90 days before the new plan can ask you to get a new prior approval for that ongoing treatment.

How to check a doctor before you choose a plan

Medicare.gov's page on joining a plan advises asking your doctors and pharmacies whether they are in network with the plan before you join. A practical way to do this:

1. List the clinicians you want to keep: your primary care clinician, any specialists you see regularly, and the hospital you would want to use.
2. Check each plan's provider directory on the plan's website, using the plan's exact name and year. A company often sells several plans with different networks in the same area.
3. Call each office and ask whether they will be in network with that specific plan for the coming year. Directories can be out of date, and the office knows which contracts it has signed.
4. Ask about referrals and approvals: if you choose an HMO, ask whether your specialist sees patients from that plan with a referral from your primary care doctor.
5. Check where you spend time: the joining page notes that if you live in another state for part of the year, you should check whether the plan will cover you there.

Free, unbiased help is available from your State Health Insurance Assistance Program (SHIP), which the joining page describes as not connected to any insurance company or health plan. You can also call 1-800-MEDICARE (1-800-633-4227).

When you can switch

You can join, switch or drop a plan only during certain enrollment periods. Medicare.gov's joining page lists them:

• Open Enrollment Period, October 15 to December 7: you can switch from Original Medicare to Medicare Advantage or back, change Medicare Advantage plans, and join, drop or switch a Part D plan. Coverage starts January 1, and the plan must get your request by December 7.
• Medicare Advantage Open Enrollment Period, January 1 to March 31: only if you are already in a Medicare Advantage plan. You can switch to another Medicare Advantage plan, or drop it and return to Original Medicare and join a separate drug plan.
• Special Enrollment Periods: for certain life events, such as moving, losing other coverage, or getting Medicaid or Extra Help.
• Initial Enrollment Period: generally the 7 months around your 65th birthday.

Outside these windows you generally have to stay with your choice, so it pays to check your doctors before December 7. If you also need drug coverage, our Part D guide explains how drug plans and their costs work.

Referrals under each option

The rules on referrals are the most common surprise for people who change coverage:

• Original Medicare: in most cases no referral to see a specialist.
• Medicare Advantage HMO: in most cases a referral from your primary care doctor, with exceptions such as yearly screening mammograms.
• Medicare Advantage PPO: no referral needed, but in-network care costs less.

Our guide to referrals covers how to ask for one and what happens if you skip it.

What T-MedInfo can and cannot tell you

What a profile shows

Clinician profiles on this site are built from public CMS data. Where CMS lists them in the Doctors and Clinicians file, a profile can show whether the clinician is marked as accepting Medicare assignment, which group practice their Medicare enrollment is linked to, and the services they billed to Original Medicare in past years. These details help under Original Medicare.

What a profile cannot show

• Plan networks: we do not have Medicare Advantage, Medicaid or private plan network data. Nothing on a profile means a clinician is in or out of any plan's network.
• New patients: whether a clinician is accepting new patients is not in the public data.
• Medicare Advantage care: the Part B service counts on profiles come from Original Medicare claims and do not include care for Medicare Advantage members.

Use a profile to find a clinician and check basic public facts, then confirm network status with the plan and the office. The specialist checklist lists the other things to check.

Questions to ask before you decide

• Are all the doctors I see regularly in this plan's network for next year?
• Do I need a referral or prior approval to see my specialists?
• Which hospitals are in network near me?
• What will I pay for specialist visits in network and, in a PPO, out of network?
• If I keep Original Medicare, does my doctor accept assignment?