Medicare Advantage provider networks limit enrollees to about half of the doctors in their area who are available to traditional Medicare beneficiaries, on average

With Medicare’s annual open enrollment period underway, a new KFF analysis finds that Medicare Advantage enrollees had, on average, access to just under half (48%) of the doctors in their area who were available to traditional Medicare enrollees.

The finding illustrates a key tradeoff for beneficiaries who choose Medicare Advantage. Such plans can be attractive to beneficiaries because they offer additional benefits and cap out-of-pocket expenses without the need for additional coverage. But plans’ provider networks, which help insurers manage utilization and costs, also limit policyholders’ choice of doctors, hospitals and other providers without paying additional fees. Changes in provider networks can be disruptive for patients when their hospitals and doctors are no longer in network.

In the analysis, KFF researchers document how much networks vary across plans by using the 2022 Medicare Advantage Provider Directories to assess the share of physicians available to plan enrollees as a share of all physicians submitting claims to provide care to traditional Medicare beneficiaries, by county, plan characteristics, and physician specialties.

Among the main conclusions:

• One-fifth of Medicare Advantage enrollees in plans with the narrowest networks had in-network access to about one-third of all doctors available to people with traditional Medicare. Conversely, one-fifth of Medicare Advantage enrollees in plans with the largest networks had in-network access to more than two-thirds of the doctors available to traditional Medicare beneficiaries.
• The size of Medicare Advantage provider networks varies widely between countries and within counties, which can make it difficult for beneficiaries to decipher which option is best for them when choosing a plan.
• The share of physicians available to Medicare Advantage enrollees varied by specialty. Generally, a larger proportion of outpatient medical and surgical specialists were in Medicare Advantage plan networks than primary care physicians.

Previous KFF research shows that beneficiaries appreciate being able to choose their own doctors, but the vast majority of the nation’s nearly 69 million Medicare beneficiaries do not compare coverage options or switch plans.

This year, the Centers for Medicare & Medicaid Services has a new tool in the online Medicare Plan Finder that allows beneficiaries to enter up to five of their preferred providers to more easily determine if they are in a plan’s network. Users can sort plans in their area based on whether or not a “must-have provider” is on the network. The Medicare open enrollment period began October 15 and will end December 7.