What Are Provider Networks and How Do They Compare?

Reviewed by: Shikita Nunnery, Licensed Insurance Agent

Key Takeaways

A network can be made up of doctors, hospitals and other health care providers and facilities.
Medicare Advantage has a provider network that must be used with Part A and Part B .
Networks help to control costs for beneficiaries and the insurance companies.
When you’re choosing a provider network, it’s helpful to make a list of your healthcare “musts” and “wants” when comparing.

What’s the Plan?

It’s not easy to make sense of healthcare. When you start researching health insurance networks, there are few things to know. Let’s start with understanding the acronyms you’re bound to come across: HMO, PPO, and POS.

You’ve decided to enroll in a Medicare Advantage plan.

Now you have another decision to make: Which Medicare Advantage plan is right for you?

While Original Medicare allows you to see any provider that accepts Medicare, Medicare Advantage plans feature a network of providers.

Generally speaking, the more willing you are to deal with regulations and restrictions related to navigating your network of providers, the more money you can save.
But for others, the ability to see out-of-network doctors or to see a specialist without a referral is worth its weight in gold.

Those differing priorities are addressed in three types of Medicare Advantage plans: the HMO, the PPO and the POS. Here is a quick summary and a table to explain HMO and PPO and what’s covered.

HMO: In HMO Plans, you generally must get your care and services from providers in the plan’s network, except:

Emergency care
Out-of-area urgent care
Out-of-area dialysis

PPO: In most cases, you can get your health care from any doctor, other health care provider, or hospital in PPO Plans. PPO Plans have network doctors, other health care providers, and hospitals.

Each plan gives you the choice to go to doctors, specialists, or hospitals that aren’t on the plan’s list, but it will usually cost less if you get your care from a network provider.

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This website is operated by GoHealth, LLC., a licensed health insurance company. The website and its contents are for informational and educational purposes; helping people understand Medicare in a simple way. The purpose of this website is the solicitation of insurance. Contact will be made by a licensed insurance agent/producer or insurance company. Medicare Supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program. Our mission is to help every American get better health insurance and save money.
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