Key Takeaways

• Medicare Advantage (Part C) plans in 2025 typically use provider networks, which means your current doctors might not be covered unless they are in-network.

• Before enrolling in a plan, you should confirm that your preferred doctors, hospitals, and specialists are part of the plan’s provider directory to avoid surprise costs or coverage gaps.

What Provider Networks Mean for You in 2025

When you join a Medicare Advantage (Part C) plan in 2025, you’re choosing a type of Medicare coverage that’s administered by private companies approved by Medicare. One defining feature of these plans is the use of provider networks. That means you usually need to get your care from doctors, hospitals, and other healthcare providers that are part of the plan’s network.

Unlike Original Medicare, which lets you see any provider that accepts Medicare, most Medicare Advantage plans limit your options. Going outside the network can result in higher costs—or no coverage at all.

Types of Networks You Might Encounter

There are several types of Medicare Advantage plans in 2025, each with its own network rules:

• Health Maintenance Organization (HMO): Requires you to use in-network providers except in emergencies. Referrals are usually needed to see specialists.

• Preferred Provider Organization (PPO): Lets you see out-of-network providers, but at a higher cost. In-network care remains cheaper.

• Private Fee-for-Service (PFFS): Some may have networks; others allow you to use any Medicare-approved provider who accepts the plan’s terms.

• Special Needs Plans (SNPs): Designed for people with certain chronic conditions or circumstances; these typically have very specific provider networks.

Understanding the plan type you’re enrolling in helps you anticipate how restrictive the network will be.

Why You Should Always Check the Provider Directory

Every Medicare Advantage plan publishes a provider directory. It lists which doctors, clinics, hospitals, and pharmacies are considered in-network.

Before you enroll:

• Look up your current primary care doctor. If they’re not in-network, you might have to switch.

• Search for specialists. If you regularly see a cardiologist or neurologist, check that they are in-network too.

• Verify hospital affiliations. Your preferred hospital might not be part of the plan’s approved facilities.

Not checking these details ahead of time could leave you with unexpected out-of-pocket expenses or force you to change providers.

Provider Networks Can Change

Even if your doctor is in-network now, that may not always be the case. Plans update their networks annually, and doctors can leave for various reasons.

It’s important to:

• Review the Annual Notice of Change (ANOC): Sent each fall, it outlines any changes to your plan’s network and coverage.

• Double-check your providers each year during Open Enrollment: From October 15 to December 7, you can switch plans if your current one no longer includes your preferred doctors.

What Happens If You See an Out-of-Network Provider?

In most HMO Medicare Advantage plans in 2025, going out-of-network means your care won’t be covered unless it’s an emergency. PPO plans may cover out-of-network care but usually at a significantly higher cost.

You may face:

• Full-cost charges for non-emergency services in HMO plans.

• Higher coinsurance or copayments in PPO plans.

• Denial of services if prior authorization rules aren’t followed.

To avoid costly mistakes, always call the plan or the provider to confirm network participation and coverage before scheduling non-emergency care.

The Referral and Authorization Factor

Network access is just one part of the puzzle. Many Medicare Advantage plans in 2025 also require:

• Referrals from your primary care physician to see a specialist.

• Prior authorization for certain services, tests, or procedures.

Even if your doctor is in-network, care may be delayed or denied if the proper process isn’t followed. This adds another layer of complexity compared to Original Medicare, which generally doesn’t require referrals.

Comparing Costs and Network Access

Cost is often what attracts people to Medicare Advantage. Premiums can be lower than what you’d pay for Original Medicare with a supplement, but those savings may come with trade-offs.

Ask yourself:

• Are the in-network providers close to where you live?

• Are you willing to change doctors or hospitals to stay in-network?

• Will you need specialist care that might require referrals?

Lower monthly premiums could mean less flexibility, higher out-of-pocket costs when you go outside the network, or restrictions that delay your care.

Emergency and Urgent Care: What’s Covered?

One exception to network rules is emergency and urgent care. Medicare Advantage plans must cover emergency services anywhere in the United States, regardless of network status. Urgent care is also generally covered even if you’re out of town.

However, once the emergency passes, you may need to return to your plan’s network for follow-up care to ensure it’s covered.

Network Adequacy Rules in 2025

In 2025, Medicare Advantage plans must meet certain network adequacy requirements set by the Centers for Medicare & Medicaid Services (CMS). These rules are designed to ensure plans offer:

• Adequate access to primary care and specialty services

• Reasonable travel time and distance to reach providers

• Enough providers to serve the number of enrollees in a given area

Still, adequacy doesn’t guarantee your specific doctor or hospital is included. The responsibility to verify falls on you as the enrollee.

How to Confirm Provider Participation

You can verify provider status in several ways:

• Use the plan’s online provider directory. These are updated frequently, but not always perfectly.

• Call the provider directly. Ask if they accept the specific Medicare Advantage plan you are considering.

• Contact the plan’s customer service. They can confirm if a provider is in-network as of your enrollment date.

This step is critical whether you are enrolling for the first time or switching plans during the Open Enrollment Period.

Enrollment Periods You Should Know

Your ability to switch plans or change coverage is limited to certain times of the year:

• Initial Enrollment Period (IEP): Begins three months before you turn 65 and ends three months after your birthday month.

• Annual Enrollment Period (AEP): Runs from October 15 to December 7 each year. You can switch between Medicare Advantage and Original Medicare or change Advantage plans.

• Medicare Advantage Open Enrollment (MA OEP): January 1 to March 31. You can switch Medicare Advantage plans or go back to Original Medicare.

• Special Enrollment Periods (SEPs): Available if you move, lose other coverage, or experience other qualifying events.

Understanding these windows helps you adjust your plan if your network no longer meets your needs.

Your Doctor’s Contract Isn’t Forever

Doctors and hospitals may choose to stop participating in certain Medicare Advantage networks. These decisions can happen with little notice and may disrupt ongoing care.

Plans are required to notify you when a significant provider leaves the network, especially if you’re currently receiving care. Still, it’s your responsibility to:

• Stay informed.

• Review any notices from your plan.

• Ask questions during Open Enrollment.

When Original Medicare Might Be a Better Fit

If keeping your current doctors is your top priority, you may want to consider sticking with Original Medicare paired with a Medigap policy and Part D drug coverage. Original Medicare has no network restrictions as long as the provider accepts Medicare.

That added flexibility often comes with higher premiums, but fewer limits on choice and referrals. In 2025, many beneficiaries are choosing based on network access rather than just monthly cost.

Don’t Rush—Know What You’re Signing Up For

Choosing a Medicare Advantage plan is a commitment for the calendar year. Once you enroll, changing plans is limited to specific times and qualifying events.

Take your time to:

• Compare networks

• Check your current providers

• Understand the referral process

• Evaluate any required authorizations

All of these factors influence how easy—or difficult—it will be to get the care you want when you need it.

Protecting Your Access to Trusted Providers

Medicare Advantage plans can work well for many people, but only if the plan includes the doctors and hospitals you trust. In 2025, provider access is a critical piece of the healthcare puzzle. If you value continuity of care, do your homework before enrolling.

Make Provider Access A Priority Before You Enroll

Before signing up for a Medicare Advantage plan in 2025, make sure it supports—not disrupts—your care. Review the provider directory, understand the referral requirements, and know how out-of-network coverage works. If you’re unsure, speak with a licensed agent listed on this website for guidance tailored to your specific situation.