Last year, Blythe Carey wanted to be sure she wouldn’t be billed for her gynecologist appointment. So she called the doctor’s office and was glad to hear that the physician was part of her Medicare Advantage plan’s network.
When Ms. Carey, 67, arrived for her appointment, she showed her insurance card to the receptionist, who didn’t question it. But weeks later, she received a bill for $963 because the doctor was not in the plan’s network.
“I wouldn’t have chosen to see this doctor if I had known that she wasn’t in network,” Ms. Carey said.
Medicare Advantage is a private alternative to the government-run traditional Medicare program that offers extra benefits the federal program doesn’t. It also has a cap on out-of-pocket expenses. But it usually requires members to use health care professionals in a plan’s network. Doctors and hospitals can leave the network plan any time, while Advantage members cannot (with rare exceptions). During annual open enrollment, which begins on Thursday, people enrolled in Medicare can choose a new Advantage plan for 2027 or go with traditional Medicare, which has no network. The deadline for deciding is Dec. 7. People with buyer’s remorse can also switch Advantage plans during the first three months of the year.
Advantage plans can change their benefits, covered drugs, costs and service areas every year. They can also drop out altogether — UnitedHealthcare and Humana, which serve 46 percent of the Advantage market, will be discontinuing plans for nearly a million beneficiaries. Most affected UHC members will have access to other Advantage plans offered by the company, a spokesman said in an email. Humana did not respond to a request for comment.
Some industry analysts who have been reviewing all Advantage plans estimate that as many as five million members will have to find new coverage for next year because of a record number of plan cancellations. About half of the 71 million Americans with Medicare are enrolled in Medicare Advantage.
Plan Finder gets an upgrade
Finding the best plan that meets multiple medical needs at the right price and includes trusted doctors and hospitals can be like winning at bingo.
To make it easier to sort through dozens of Advantage plans, the Centers for Medicare & Medicaid Services has upgraded its indispensable Medicare Plan Finder website.
For the first time, beneficiaries and those who help them can type in the name of any licensed health care provider — not just doctors, which was the case last year — and find which Advantage plans they accept.
Medicare officials have said the Plan Finder’s provider information will “promote informed beneficiary choice and transparency.”
To run a search for plans, go to medicare.gov/plan-compare, enter your ZIP code, then select Advantage plans and follow the prompts for your prescription drugs, preferred pharmacies, doctors and other factors to get a list of plans. To search for a hospital, nursing home or other facility, select “plan details” and then “view facilities.” The details page also displays which of the more than three dozen extra benefits are covered. Another change: The Plan Finder will indicate up to 15 addresses for each physician, since their network participation can vary by location.
The Plan Finder can be used without creating a personal Medicare.gov account, which requires a Medicare beneficiary number and identity verification, but only account holders can save search results.
The finder’s improvements could help people like Ms. Carey as well as Mary Ann Davis, who spent “many, many, many hours” last year checking individual insurance company and physician websites to find an Advantage plan that included her primary care physician, dentist and periodontist.
Before signing up, Ms. Davis also called the insurer to confirm information she read on its website. “I was doing all my due diligence to make sure I didn’t pay too much out of pocket,” said Ms. Davis, who is in her 70s and lives in central Virginia. When she went to the periodontist in March, the plan’s network had changed, but no one told her. Later, she received a bill for $1,906 on top of the $550 she had paid in advance. “All that work I had done didn’t do me any good,” Ms. Davis said.
Advantage plans must cover everything Medicare does, including prescription drugs and medical care. They also offer many extra benefits, such as dental and vision care, transportation, groceries and over-the-counter pharmacy items at little or no cost. Insurers can afford to offer these extras partly because they receive government subsidies. This year, they are projected to receive about $615 billion — or roughly 14 percent more than the government pays to care for similar patients in traditional Medicare, according to the Medicare Payment Advisory Commission, which monitors the program for Congress.
A recent KFF study uncovered another reason it’s important to check networks: They can vary by plan and by county. Researchers found that in 2022, the networks included only about half as many doctors on average as traditional Medicare. C.M.S. requires plans to have enough providers to meet members’ needs and sets limits for how long and how far members should have to travel to reach them.
Better, but not perfect
The government has recognized that the provider search function on the Plan Finder may have some flaws. When a physician-only search for 2026 Advantage plans was introduced, the rollout was rocky even though insurers must affirm the information is accurate and revise it within 30 days of learning about a change.
“Some provider directory information may be incorrect, especially in its first year,” according to a C.M.S. fact sheet. So officials had allowed members to change their Advantage plan in 2026 if the one they chose was based on inaccurate Plan Finder provider information. But this provision will not be available for 2027 plan sign-ups, a C.M.S. spokesman said in an email.
The American Hospital Association, which represents nearly 5,000 hospitals in the United States, wants that option to be extended.
“If patients rely on a plan’s incorrect provider network information in the Plan Finder, or their Medicare Advantage network changes midyear by losing a hospital they depend on for care, they should have the opportunity to switch their coverage to ensure that their medical care is in network,” Molly Smith, group vice president of policy for the association, said in an email.
Health care groups generally welcome the Plan Finder improvements but caution people about its shortcomings. Even if its information is correct, it will not indicate when contracts between providers and insurers are scheduled to end. If the sides can’t agree on a new contract, the providers will no longer be in network.
Provider-insurer contracts usually do not coincide with the beneficiary’s enrollment period (one calendar year). UnitedHealthcare Medicare Advantage plans and NewYork-Presbyterian Hospitals, with facilities throughout the city and suburbs, extended their contract several times this year and are still in negotiations. Without an agreement or another extension, the hospital system will leave UnitedHealthcare starting Nov. 1.
The Plan Finder also won’t show if an in-network provider is accepting new patients.
“It cannot guarantee that a particular facility is available and appropriate to meet an individual’s unique clinical needs,” said Nisha Hammel, a vice president at the American Health Care Association, whose members include skilled nursing centers and other long-term care facilities.
Even if an in-network facility is taking new patients, she said, the insurer may not approve or continue care for the length of time their doctors say is medically necessary.
“Families should always contact both the skilled nursing facility and their health plan directly — and, when possible, visit the facility — to determine if it is the right fit,” Ms. Hammel said.
Who is responsible?
More improvements to accuracy are expected for the Plan Finder in 2028. Willie Underwood III, president of the American Medical Association, said he welcomed those changes. The plans will have to verify provider network information every 90 days in their directories and, if they can’t, flag it as possibly outdated. When physicians leave a network, their names must be removed within five business days. The Plan Finder will import insurers’ directory information daily.
But Dr. Underwood said insurers should not blame physicians for information that’s not updated. “Medicare should require plans to use the information they already have to verify directory data before relying on physicians to confirm it,” he said in an email.
AHIP, an industry group that represents many Advantage plans, disagreed. In an email, Chris Bond, the group’s spokesman, said insurers were committed to keeping Plan Finder information current, but that requires “continued collaboration among C.M.S., providers and health plans.”
Ms. Carey disagrees with both groups: “Why is the onus on the patient? Why is it on the patient to determine whether a doctor is a network? I just find it really unfair.”
Ms. Davis thinks an accurate one-stop provider directory would save time and frustration for some members. “But why would you want to even bother with it if a provider is not going to be in the network for the entire year you have the plan? I think it’s false advertising.”
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