Having the freedom to choose Medicare providers and having flexibility in healthcare coverage options are essential factors for many seniors. This is especially true for “snowbirds” and those who want to maintain control over their healthcare decisions, no matter where they are.

In this blog post, we will discuss the basics of in-network and out-of-network Medicare provider copays and how Gold Kidney Health Plan offers a unique and appealing alternative for those who want flexibility in their healthcare choices.

Understanding In-Network and Out-of-Network Provider Copays

In-Network Providers

In-network providers are healthcare professionals or facilities that have agreed to work with your insurance company offering services at pre-negotiated rates. When you visit an in-network provider, you typically pay less out of pocket because your insurance plan covers a significant portion of the cost. This cost-sharing mechanism is usually in the form of a copayment, or copay, which is a fixed amount you pay for a covered service, such as a doctor’s visit or a prescription medication. The copay for in-network providers is consistent and often lower than what you’d pay for out-of-network care.

Out-of-Network Providers

Out-of-network providers, on the other hand, do not have agreements with your insurance company, and the costs associated with their services are generally higher. When you visit an out-of-network provider, your insurance plan may still provide coverage, but the cost-sharing structure can be different. Instead of a copay, you might be responsible for a percentage of the total cost, or coinsurance, and your deductible may be higher. In this case, you’ll often pay more out of pocket for the same services compared to using in-network providers.

The Gold Kidney Difference

At Gold Kidney, we understand that healthcare flexibility is important to you, especially if you want the freedom to choose your Medicare doctors, specialists, and healthcare providers. That’s why we have designed HMO-POS Medicare Advantage plans that cover members at the same copay for doctor and specialist visits and preventative care, regardless of whether the Medicare provider is in- or out-of- network. This lets you manage your care the way you want.

Gold Kidney’s provider network is extensive (click here to search for your provider – link to Provider Search) and is growing every day. But with our Medicare Advantage plans, it’s nice to know that if you go outside our network, you’re covered.

Here are some benefits of our HMO-POS Medicare Advantage plans*:

  1. Freedom to choose: With Gold Kidney Health Plan the choice is yours – choose your healthcare provider, regardless of whether they are in or out of our extensive Medicare provider network. Whether you’re a “snowbird” or traveling to visit the grandkids, you only need to find a provider that accepts Medicare, and you pay the in-network rate.
  2. $0 copay for primary care physicians and most specialists: Visits to your primary doctor and most specialists come with a $0 copay, ensuring that getting the care you need is as straightforward and budget-friendly as possible.
  3. $0 copay for preventative care and screenings: Your well-being is our top priority. Preventative care and screenings are essential to living a healthy, happy life, wherever you might be – Gold Kidney’s $0 copays make living your best life easier.
  4. Flex Card benefits: With up to $4,000* in Flex Card allowance dollars to cover dental, hearing, and vision expenses, Gold Kidney Medicare Advantage plans work for you and give you the ultimate flexibility.

*Benefits vary by plan

Understanding the differences between in-network and out-of-network provider copays is essential to help you control medical expenses and make informed decisions about your care. By staying informed and having convenient tools to verify provider status, you can navigate the complexities of healthcare coverage and benefits with confidence.

If you’re looking for a Medicare Advantage plan that gives you the option to see the Medicare providers of your choice, gives you peace of mind when you’re away from home, and allows you to live your best life, we have a plan that is right for you.

Call us at 844-294-6535 (TTY: 711) or complete this form below. We will be happy to assist you.

Out-of-network/non-contracted providers are under no obligation to treat Plan members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

Gold Kidney Health Plan, Inc., is an HMO-POS, HMO-MA, and HMO-POS C-SNP with a Medicare contract. Enrollment in Gold Kidney Health Plan depends on contract renewal.