Network Restrictions

Prior Authorization and Coverage Denials

Even if your doctor is included in your Medicare Advantage plan’s network, Medicare Advantage plans can limit the care your doctor can provide. 

99 percent of Medicare Advantage plans require prior authorization for services covered by traditional Medicare, like skilled nursing, short-term hospital stays, and durable medical equipment. 

This means your doctor must get permission from your Medicare Advantage plan before you can get recommended medical equipment or treatment, such as oxygen equipment, surgery, or physical therapy. The Medicare Advantage plan staff making these care decisions typically are not physicians and may not be medical professionals at all. 

Each Medicare Advantage plans also uses its own guidelines to make coverage decisions, and these guidelines are not the same used by traditional Medicare. The result is that Medicare Advantage plans deny coverage much more often than traditional Medicare, including care that traditional Medicare covers. 

Talk to Your Doctor About the Risks of Medicare Advantage

Medicare Advantage plans are not a substitute for traditional Medicare. 

Talk to your doctor before choosing a Medicare Advantage plan and make sure you have all the facts before deciding about your health care coverage.