Does your doctor take your exact Medicare plan?

You call a doctor's office and ask, “Do you take Medicare?” The answer is yes. That sounds reassuring, but if you have a Medicare Advantage plan, there is another question to ask: “Is this doctor in the network for my exact plan at this office location?”

Getting specific before your annual review can help you avoid assumptions about access to care. You do not need to memorize insurance terminology. You need the right plan name, the right provider and a clear record of what you checked.

Start with the kind of coverage you have

With Original Medicare, provider participation and whether the provider accepts Medicare assignment matter. Assignment means accepting the Medicare approved amount as full payment for a covered service, subject to your applicable deductible and coinsurance. Ask the office about your situation. Read Medicare’s explanation of assignment.

With Medicare Advantage, check the particular plan's rules and provider network. Recognizing the insurance company's name is not enough to confirm participation in every plan it offers. Medicare.gov directs people with Medicare Advantage to check with their plan about network membership.

Make a short list of the care you want to keep

Write down your primary care doctor, specialists and facilities you use. Include each provider's full name and the specific office location. If an appointment or procedure is already planned, note that privately so you can ask the relevant questions during your review.

Keep this list for your own review. Do not put Medicare numbers, medical records or appointment details in public comments or social messages.

Check both the plan and the office

Use the plan's current provider directory as a starting point. Then ask the plan and the provider's office to confirm the exact plan, provider, location and applicable year. Ask whether the office is accepting new patients if that applies to you.

For a future plan year, make the year explicit. An answer about today's participation does not establish next year's status. If the applicable information is not yet available, record the question as unresolved and check again when it becomes available. Do not treat a missing answer as confirmation.

Save the date of your check and any reference number the plan supplies. Networks can change, so check again when scheduling care. See Medicare’s provider network fact sheet. If the directory and office disagree, ask the plan to resolve the discrepancy before relying on either answer.

Understand the plan's rules before using a provider outside its network

An HMO generally requires network care, with exceptions including emergency care, urgent care outside the area and temporary dialysis outside the area. Some HMO plans offer a point of service option. Check the exact plan documents instead of assuming that an exception applies to a routine appointment. Read Medicare’s HMO overview.

A PPO generally allows covered care outside the network at a higher cost. That does not make every service automatically covered. Medicare.gov recommends contacting the PPO before getting services outside its network to confirm the services are medically necessary and covered by the plan.

Network participation is one part of the review. Depending on the plan and service, referrals or prior authorization may also matter. Confirm those requirements with the plan.

Bring unresolved questions to your annual review

Medicare Open Enrollment runs October 15 through December 7. Use the weeks before it to organize questions, rather than assuming you must make a decision as soon as a mailing arrives.

Our annual review preparation guide helps you gather doctors, prescriptions, pharmacies and priorities in one place. Good Life Insurance serves Clemmons and the Triad, with English and Spanish service. Book a private conversation when you are ready to review your questions. A review does not guarantee that a particular provider or service is covered.

Keep a simple record of your checks

This is a personal preparation worksheet, not proof of coverage. Keep it somewhere private and share it only through an appropriate secure process.

Educational information only. Your plan's current documents and confirmed provider participation control. Good Life Insurance is not connected with or endorsed by the U.S. government or the federal Medicare program.