What Does It Mean When a Hospital System Leaves Your Medicare Plan's Network?

Written By George Kraft

Educational guide — Senior Benefits Alliance

You may have received a letter from a hospital system saying it is now "out-of-network" for your Medicare Advantage plan. That kind of letter raises real questions. Here's what it actually means, in plain English — and what to check before you make any decisions.

What "out-of-network" means

Your Medicare Advantage plan contracts with a network of hospitals and doctors. When a hospital system leaves that network, it is no longer under contract with your plan. What happens next depends mostly on one thing: your plan type.

HMO vs. PPO — this is the big one

  • HMO plans generally do not cover out-of-network care except in emergencies. If your hospital leaves the network, you may need to change hospitals — or change plans.

  • PPO plans typically let you see out-of-network providers, usually at a higher cost share than in-network care. Some PPO plans are designed so that in-network and out-of-network costs are similar. Your plan's Evidence of Coverage (EOC) spells out the exact numbers — that document, not the hospital's letter, is the source of truth for what you'll pay.

Five things to check before you decide anything

1. Your plan type. HMO or PPO — it's on your member ID card and in your Evidence of Coverage.

2. What your plan actually pays out-of-network. Look at the out-of-network cost-sharing section of your EOC.

3. Whether your own doctors are affected. A hospital system leaving a network doesn't always mean your personal physician left. Many physicians bill independently of the hospital — confirm with each doctor's office directly.

4. Your prescriptions. A hospital network change doesn't change your plan's drug formulary, but the Annual Enrollment Period is the right time to confirm all of your medications are still covered.

5. Your timeline. The Annual Enrollment Period (October 15 – December 7) is when you can switch Medicare Advantage or Part D plans for a January 1 effective date.

Questions worth asking

Ask your plan:

  • What will I pay if I keep seeing my current providers out-of-network?

  • Do I need referrals or prior authorizations for out-of-network care?

  • Is there a separate out-of-network deductible or out-of-pocket maximum?

Ask yourself:

  • How often do I actually use this hospital system?

  • Are my most important doctors affected, or just the facility?

  • Would a different plan cover my doctors and my prescriptions at a cost I can live with?

Our philosophy

There is no perfect insurance — there are only pros and cons. The right move depends on your doctors, your prescriptions, your budget, and how you use care. A generic letter can't answer that for you, because it doesn't know your situation. An individual review can.

Talk it through with a licensed agent

If you received one of these letters and want to understand your options, we'll walk through your specific doctors, medications, and costs — at no cost to you.

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Disclaimer: We do not offer every plan available in your area. Currently we represent 9 organizations which offer 95+ products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options

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George Kraft