People who live in rural communities often have limited access to hospitals and doctors.
“I want to continue seeing my doctor. How can I be sure they won’t go ‘out of network?’”
When deciding whether to enroll in Original Medicare or Medicare Advantage, you should consider where you prefer to receive hospital, doctor and pharmacy care, and whether the healthcare providers in your rural community are “in network” with the insurance that interests you. While typically Medicare Advantage restricts the doctors and hospitals you can use, a Medicare Advantage plan that is sponsored by your local hospital would most likely allow you to continue seeing the doctors you trust in your community.
It is also important to know that Medicare Advantage sponsored by private insurance companies often requires additional approvals before you are able to have a procedure or receive care. This could put your local hospital at financial risk if the Medicare Advantage plan is not provided by the hospital.
Access to Care in Rural Communities
Pro Tip: Consider where you spend most of your time and seek insurance coverage that is in network there.
Original Medicare |
Medicare Advantage managed by Private Insurance Companies |
Medicare Advantage managed by Hospitals |
| Original Medicare provides patients with access to any doctor or hospital nationwide that accepts Medicare. Your local hospital and doctor likely accept Original Medicare. | Medicare Advantage plans contract with doctors and hospitals to create networks and have the power to choose which providers are or are not in network. Your local hospital and doctor might not be in network. | Hospitals form a local network of their own hospitals and doctors that would be in-network for your care. You may be out of network if you seek care outside of your primary living area. |
| Original Medicare allows you to keep the local doctors and hospitals you trust. | Your local hospital and/or doctor may offer a Medicare Advantage plan that would put you in-network. However, Medicare Advantage plans can drop doctors and hospitals from the network and assign you to new providers who are in network. | Hospitals form a local network of their own hospitals and doctors that would be in-network for your care. Hospitals have the opportunity partner with specialty services so they are considered in-network. |
| Original Medicare permits you to purchase Medigap insurance – or supplemental insurance – that can cover things like your 20 percent co-insurance and other out-of-pocket expenses. | Medicare Advantage plans do not permit Medigap insurance. And Medicare Advantage plans can deny payment for services they deem unnecessary or that didn’t receive prior authorization. Patients are responsible for costs that are denied or out of network. | Medicare Advantage plans do not permit Medigap insurance. While services could be denied due to no authorization, hospital-based plans have better opportunity to closely coordinate care. |
Before You Enroll
- Ask your preferred hospital and doctor if they sponsor a Medicare Advantage plan of their own that they offer patients.
- Ask yourself how far you are willing or able to drive for care. If you want assurance that you can stay with your local hospital or doctor, Original Medicare or a Medicare Advantage Plan sponsored by your local hospital may be better for you.
- Ask yourself if you plan to travel. For example, if you travel to a warmer climate during winter months, and you have Medicare Advantage, you may be out of network when you travel. Original Medicare is accepted nationwide.
- Consider the kind of care you are receiving and ask your doctor and/or hospital if Original Medicare or Medicare Advantage would be a better option. For example, if you are relatively healthy and require little access to specialty care, Medicare Advantage may work well. If you need specialty care such as behavioral health, cardiology or cancer care, Original Medicare with a supplement may be a better choice.
- Understand that a restricted network can have negative implications for continuity of care and overall patient experience.
- It is important to know that rural hospitals generally do not receive as much payment for Medicare Advantage patients as they do for Original Medicare patients.
Here are additional resources to help you make the best choice between Original Medicare and Medicare Advantage.
Medicare Open Enrollment Season runs Oct. 15 – Dec. 7, 2024
Now is the time to make sure you’re choosing the best Medicare option for you in 2025.
For more information visit Medicare.gov