Medicare · Cornerstone
Finding a doctor with Medicare, networks and referrals
Last reviewed June 11, 20262 min readBy the Goodsurance editorial team Reviewed by the Goodsurance editorial team
How you find and pay a doctor depends almost entirely on which path you chose, and provider access is one of the biggest practical differences between Original Medicare and Medicare Advantage. It is also one of the most common sources of confusion at the point of care, when "do you take my insurance" turns out to have a more complicated answer than yes or no. Here is how each path works and what the billing terms actually mean.
1Original Medicare: no network, but read the fine print on acceptance
The defining feature of Original Medicare is that there is no network. You can see any doctor, specialist, or hospital in the country that accepts Medicare, without a referral. For people who travel, split the year between two states, or want a specific specialist, this freedom is the main reason they choose this path.
The nuance is in what "accepts Medicare" means, because there are three postures a provider can take, and they change your bill. The practical move is to ask not just "do you take Medicare" but "do you accept assignment," because that second question is the one that tells you what you will actually pay.
- Medicare's approved amount is full payment
- You pay your normal share, nothing extra
- Can add a limited excess charge
- A Medigap plan can cover it
- Bills you privately by contract
- Medicare pays nothing, ask directly
2Medicare Advantage: networks and, sometimes, referrals
Medicare Advantage plans work more like the employer coverage most people had before retirement: there is a network of contracted providers, and your costs and access depend on staying in it. How strict that is depends on the plan type, HMO plans generally cover only in-network providers except for emergencies and often require referrals to specialists, while PPO plans let you go out of network at a higher cost and usually do not require referrals.
Because the network is the plan, the single most important step before choosing an Advantage plan is confirming that your doctors and your preferred hospital are in it, and that the drug list covers your medications. Networks can also change from year to year, so a plan that included your doctor last year may not this year.
3Checking before you commit
Whichever path you are on, verify rather than assume. Medicare's Care Compare tool at Medicare.gov lets you look up providers, and Advantage plans publish provider directories. The catch with any directory is that it can be out of date, so the reliable step is to call the office directly. Five minutes on the phone prevents the most common and frustrating surprise in this whole area, finding out at the front desk that the answer changed.
Verify before you decide
Are your doctors and hospital in the current directory?
Directories go out of date; check this year's
Does the plan's drug list cover your medications?
For Advantage and Part D plans
Call the office with two questions
Do you accept assignment, and are you taking new Medicare patients
Common questions about Medicare
Quick answers to common questions
Tap any question to expand. Each question links to a fuller standalone answer.
References
- Medicare.govProvider access under Original Medicare, assignment, and the Care Compare tool.
- CMS, Centers for Medicare & Medicaid ServicesParticipating, non-participating, and opt-out provider rules. cms.gov