Provider Network
A provider network is the group of doctors, hospitals, and other providers that contract with a plan. Medicare Advantage plans use networks; staying in-network lowers your costs, while Original Medicare lets you use any provider that accepts Medicare.
Understanding Provider Network
A provider network is the group of doctors, hospitals, pharmacies, and other providers that have contracted with a Medicare Advantage plan to deliver care at agreed-upon rates. Medicare Advantage plans (HMOs and PPOs) use networks to control costs; Original Medicare has no network, so you can use any provider in the country that accepts Medicare.
For beneficiaries, the network is one of the most important things to check before enrolling. Staying in-network keeps your costs low, while going out-of-network can mean higher cost-sharing or no coverage at all, depending on the plan type. Networks can also change during the year, so a doctor who is in-network in January may leave the plan later.
For example, if your longtime cardiologist is not in a plan's network, an HMO might not cover those visits at all, while a PPO would cover them at a higher out-of-pocket cost. Always verify your providers are in-network for the specific plan year.
Have questions about provider networks? Get a free Medicare review and we will confirm your doctors and hospitals are covered before you enroll.
Related Terms
Health Maintenance Organization (HMO)
An HMO is a Medicare Advantage plan type that generally requires you to use in-network providers and choose a primary care doctor, with referrals to see specialists. Out-of-network care is usually covered only in emergencies.
Preferred Provider Organization (PPO)
A PPO is a Medicare Advantage plan type that lets you see any provider, with lower costs in-network and higher costs out-of-network. PPOs generally do not require referrals to see specialists.
Medicare Advantage
Medicare Advantage (Part C) is an alternative to Original Medicare offered by private insurance companies approved by Medicare. These plans include Part A, Part B, and usually Part D coverage in one plan.
Need Help Understanding Your Options?
A licensed Medicare advisor can explain how provider network applies to your specific situation.
Get a Free Medicare Review