Is Your Doctor in Your Medicare Plan? Now’s the Time to Find Out.

Retirees in Medicare Advantage plans may have a hard time finding a doctor who takes the insurance. (Dreamstime)

Key Points

• Medicare Advantage enrollees had access to 48% of doctors available to traditional Medicare users nationwide, based on 2022 data.
• Access to medical providers varies significantly by location, with San Diego at 18% and Pima, Ariz., at 58%.
• Changes in provider networks are common; for example, the Mayo Clinic will no longer accept UnitedHealthcare and Humana Advantage plans.

Medicare Advantage plans are supposed to make life easier for retirees by bundling all their healthcare needs together. But one of the most basic tasks—finding a doctor who takes your plan—isn’t always that simple.

The vast majority of doctors take traditional, government-run Medicare, and enrollees can visit anyone they want nationwide. By contrast, privately run Medicare Advantage plans impose restrictions on which doctors and hospitals their members can use, leaving consumers far less choice.

Nationwide, retirees in Advantage plans had access to 48% of the doctors available to those on traditional Medicare in their area, according to a study by KFF, a health policy nonprofit, based on 2022 data. There were wide disparities by location: Advantage enrollees in San Diego had access to only 18% of doctors who take traditional Medicare. In Pima, Ariz., it was 58%.

Choice of medical providers is a key factor to weigh this Medicare open-enrollment season, which runs through early December. Enrollees have until Dec. 7 to make a switch for 2026. During this time, Advantage members can change plans or leave the program altogether and return to traditional Medicare, although you generally aren’t guaranteed the ability to buy a Medigap supplement plan when you return. People on traditional Medicare can pick a new stand-alone Part D drug plan or switch over to Advantage.

Many Advantage plans advertise extras like gym and dental benefits. But these perks, not covered by traditional Medicare, shouldn’t be the deciding factor in choosing coverage, experts say. Instead, the ability to see your doctors will likely have a bigger influence on your health and satisfaction with the plan.

Restricting doctor access is one lever that insurers use to control costs, and many Advantage carriers have been struggling with profitability over the past couple of years, says Vijay Kotte, CEO of GoHealth, a Medicare broker. Even if all your doctors participate in your plan this year, there could be changes in store for 2026.

Problem is, it isn’t always easy for Advantage enrollees to determine who is in or out of their network. And it’s nearly impossible to predict which specialists you might need if your health changes. There’s a “tremendous burden on beneficiaries to figure it out,” says Matthew Rae, co-author of the KFF study.

Changes to provider networks can come from both directions: Advantage plans can drop doctors and medical groups from their networks, and providers themselves can stop taking Advantage plans. Starting in January, for instance, the Mayo Clinic in Rochester, Minn., and its regional Mayo Clinic Health System will no longer accept Medicare Advantage plans from UnitedHealthcare and Humana. Those facilities will be out-of-network for affected plan members.

A spokesperson for the Mayo Clinic said patients should “confirm their coverage and network access with their Medicare Advantage plan before enrolling for the upcoming year.”

To stay on top of provider changes, pay close attention to your mail. During open enrollment, it can be hard to sort the real correspondence from advertisements, but keep an eye out for a letter from your plan that will alert you to provider changes. Insurance brokers can help, but make sure your broker works with a range of insurance companies and be wary of aggressive sales tactics that might indicate a financial incentive to steer you toward one plan over the other.

Medicare’s online Plan Finder tool asks about your medical providers so it can search for plans they participate in. Cross-check this information—and anything you might find on an insurer’s website—with your doctors. Give their office the full name of Advantage plans you’re considering to make sure they’re in network.

If your plan is being discontinued, you have to actively enroll in a new Advantage plan to stay in the program. Otherwise, you will be defaulted to traditional Medicare and may be given a guaranteed window to buy a Medigap plan for the 20% of covered costs that Medicare doesn’t foot.

Outside of your initial Medicare enrollment period and certain limited circumstances, you have to pass medical underwriting to buy a Medigap plan. This requirement prevents many people in less-than-stellar health from leaving an Advantage plan for traditional Medicare.

Write to Elizabeth O’Brien at elizabeth.obrien@barrons.com