Medicare Advantage Plans: Beware of Concentric Networks

Medicare Advantage Plans: Beware of Concentric Networks


The Medicare Annual Election Period (AEP) is upon us and Health Insurance companies are spending heavily on marketing to lure beneficiaries into low-cost plans.


Typically, most Medicare beneficiaries who enroll in Medicare Advantage (MAPD) plans enroll in an HMO plan. These HMO plans look attractive due to their low premium (most have a $0 premium), low copays, and additional benefits not covered by Original Medicare (like dental and vision). However, some unattractive characteristics of HMO MAPD plans are the lack of provider network flexibility and concentric networks.


Unless you have an Open Access plan, you must get a referral from your Primary Care Physician to go to a specialist. This may sound similar to individual/family HMO health insurance plans, but the main difference with the Medicare Advantage HMO is a term called concentric network. With a concentric network, the Primary Care Physician works with a selected group of Specialists who he refers to.


Here’s how it works:


You need to go see an orthopedic doctor for a shoulder injury. A few of your friends have recommended a particular orthopedic doctor who they have had great experiences with. You go to your Primary Care Physician to get a referral to see said doctor, but you learn your PCP will not refer you to that particular doctor. Instead, your PCP wants to refer you to a different orthopedic doctor.


Because the doctor works with certain selected doctors, it leaves the member with a lack of flexibility in provider choice. Not only can you only go to In-Network providers, but now you are also at the mercy of the PCP to refer you to a specialist.

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