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The good, the bad, and the ugly

Networks in health plans have received a bad reputation. Everyone knows someone who has a bad experience being denied seeing a particular doctor. No one wants to be restricted when it comes to access to healthcare. Today’s topic is all about networks. We have already discussed that a Medicare supplement is true freedom. You will not have a problem if the doctor accepts Medicare. Stop reading this right now if you can afford a supplement and you hate networks of doctors. Please read on if you are considering a Medicare advantage plan. One more thing, this article will be geared more towards the Medicare recipients in North Carolina.



Here in NC we have some of the greatest health systems in the country. Duke, UNC, Wake Med, and Vidant are just a few. This is one the greatest states to live in for people who suffer from serious health conditions such as heart disease or cancer. We have several doctors that are trailblazers in their field of study. People will travel from all over the world to see our premier doctors. I truly am thankful for the great health systems we have her in NC.

Medicare advantage plans have worked hard to expand their networks over the past five years. They understand that access to healthcare directly affects membership enrollments. I know from experience you have an exceedingly small chance of a client switching plans if their doctors are not in network. It does not matter if the plan has lower premiums, lower co-pays, or extra benefits. Ninety five percent of the time those benefits will not matter to someone if they cannot access their established doctor. I have seen smaller Medicare advantage companies come and go in NC. Most of the time the going is directly tied to small networks. The major Medicare advantage players understand this and have made huge expansion in their networks over the past few years. Let us take a closer look of how networks work in Medicare advantage plans.


HMO stands for Health Maintenance organization. When it comes to the worst of the worst reputation, HMO’s have it. Agent’s may have been trained in the past to avoid mentioning this name when selling under sixty five traditional health plans. These types of plans were extremely restrictive back in the day. Not so much in today’s environment. The whole idea of an HMO is to control costs by controlling access. In theory, this will result in lower premiums and co-pays. Here is the run down on how they work. You must stay in network with an HMO. There is only one exception to the rule. You can go out of network if it is an emergency. In network price will be applied if out of network due to an emergency. A primary care doctor must be established. The primary care doctor is the gatekeeper. You must receive a referral from your primary care doctor to see a specialist. This detail has been the biggest inconvenience in the past. A few advantage companies have now made their HMO plans to be referral free. This is great way to attract potential enrollees. HMO’s have made big strides in access and typically offer the lowest premiums and co-pays out of all types of network plans.


PPO stand for Preferred Provider Network. PPO’s count for most Medicare advantage plans. It is kind of the best of both worlds. You will save money by staying in-network, but you have the option of going out of network for a higher cost. Emergency care applies the same to PPO plans. You would pay in-network costs whether in or out of network. A PPO works out great to retirees who like to travel or see family in other states. PPO plans can have nationwide networks. There is one detail that is extremely important that recipients must realize. Medical providers are not under obligation to offer you medical services if they are out of network. I t is up to the medical provider to accept the insurance companies’ terms for payment. Most people think they can go anywhere when they have a PPO, but this is not entirely true. A PPO does offer greater access and less hoops to jump through. PCP is recommended but not required with some companies. Referrals are not required with a PPO. This type of plan may not have the lowest premiums and co-pays, but it is a good trade-off for those who wanted easier and greater access.


Let me at least mention a PFFS. This stands for Private Fee for Services. These plans are mostly dead, especially here in NC. This type of plan was extremely popular a little over a decade ago, but it died because of its many flaws. A PFFS does not have any networks. That sounds good, right? In theory it was great, but it turned out to be mostly a theory. A PFFS plans works in the following way. The plan has a stated set of copays, costs, and deductibles. It is totally up to the doctor to figure out what that is and accepts the plans terms and conditions. This is the first fatal flaw. Doctors are already burdened down with paperwork and red tape. They have a hard-enough time receiving reimbursement from the insurance company. This adds a whole new level of difficulty. The doctor may have zero working relation with that insurance company when accepting the terms and conditions of the PFFS. Payments are more streamlined when a doctor is already part of a network. More and more doctors rejected this type of plan. Members were getting frustrated being rejected at the doctor office. Members started disenrolling at a rapid pace. The unpopularity eventually killed the plan. I personally have not seen a PFFS in NC in several years.

I hope this article has helped you understand Medicare advantage networks.


Again, networks have had a bad connotation in the past. Thankfully, networks are extraordinarily complex and efficient in today’s NC market. They are continually getting better and better. Please reach out to me if you have any questions or concerns about your Medicare. Feel free to join the blog, comment, and like us on Facebook!

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