If a member obtains preventive care from out-of-network providers, who is responsible for the costs?

When a member seeks preventive care from out-of-network providers within a Medicare Advantage plan, they are generally responsible for the costs associated with those services. Medicare Advantage plans often have specific network requirements that need to be adhered to for benefits to be fully covered. If a member chooses to go outside this network for preventive care, the plan typically does not cover these services at the same rate as in-network care.

This means that the financial responsibility falls to the member, as they opted to use services from providers that do not participate in their plan’s network, which generally means they may have to pay the full amount out of pocket. Understanding this aspect of Medicare Advantage plans is crucial for members, as it highlights the importance of using in-network providers to minimize costs and ensure comprehensive coverage of their healthcare needs.