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Can I use my Medicare Advantage plan as I travel throughout the United States?

Category: Traveling with Your Medicare plan
Updated: Oct, 24 2023

Yes, but . . . You can travel and use your Medicare Advantage plan coverage - however, depending on your Medicare Advantage plan, certain restrictions may apply to your healthcare coverage as you travel outside of your home network.

For example:
  • Your Medicare plan may require that you have a referral or gain prior authorization before seeking out-of-network coverage - or you will need to pay the healthcare costs yourself;
  • and, if out-of-network care is allowed, you may pay more for your out-of-network Medicare Part A and Medicare Part B healthcare coverage;
  • and your out-of-network coverage may not count toward reaching your Medicare Advantage plan’s maximum out-of-pocket spending limit for covered Part A and Part B services (MOOP);
  • or your Medicare Advantage plan may have a higher out-of-network MOOP limit -- for example, a $6,700 in-network MOOP, but a $13,300 combined in- / out-of-network MOOP.
On a positive note: Medicare Advantage plans provide coverage for out-of-network (and maybe out-of-country) Emergency Care just as in-network care.

Usually a Medicare Advantage plan will cover “emergency care” as you travel – even when you receive the healthcare out-of-network (see the example Evidence of Coverage text below explaining network coverage).

However, Medicare plan documentation is fairly specific when defining emergency care, and it is not to be confused with routine healthcare.  In your own plan documentation, you may read:
"'Emergency Care' - Covered services that are: 1) rendered by a provider qualified to furnish emergency services; and 2) needed to treat, evaluate, or stabilize an emergency medical condition."

And a "medical emergency is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse."
You will also wish to look closely at any limitations for "emergency care" provided by your Medicare Advantage plan.  For example, your Medicare Advantage plan may have a copay for emergency care that is waived only if you are admitted to a hospital within a specified time after the emergency care (for example, within 24 hours).

Your Medicare Advantage plan may also provide worldwide emergency care, but with an annual limit (for example, "$50,000 maximum benefit for worldwide emergency and urgently needed care annually").

And what happens if you were wrong and it was not really an emergency?
If you reasonably thought that your "health was in serious danger", your Medicare Advantage plan should cover the out-of-network cost even if it found that there was no medical emergency.  However, any additional care may be covered only by a network provider or under the plan rules regarding “urgently needed” services.

Reviewing your plan's coverage documents to learn more about in-network and out-of-network coverage.

You can review your Medicare Advantage plan’s documentation (Evidence of Coverage document) for specifics about how out-of-network care is covered – at what cost - and whether you need a recommendation from your primary care physician (PCP).

For example, if you are enrolled in a Medicare Advantage HMO, you probably will find that your plan will provide out-of-network, non-emergency coverage as you travel outside of the plan’s healthcare network – with your PCP's referral or approval and you may find some text in the Explanation of Benefits document such as:
“If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider.  In this situation, you will pay the same as you would pay if you got the care from a network provider.  Before seeking care from an out-of-network provider, talk to your primary care provider (PCP).  He or she will notify us by requesting approval from the plan (“Prior authorization”).

If you get non-emergency care from out-of-network providers without prior authorization, you must pay the entire cost yourself.

Limited cases such as emergency care, urgently needed services when our network is not available, or dialysis out of the service area, do not require prior authorization and are always covered at the network benefit level, even when you get them from out-of-network providers.” [emphasis added]
Bottom Line:  Be sure to check with your Medicare Advantage plan’s Member Services before seeking out-of-network healthcare.

Your maximum out-of-pocket limit and out-of-network, non-authorized, or supplemental care
All Medicare Advantage plan will have a maximum out-of-pocket spending limit (MOOP) for your Medicare Part A and Medicare Part B benefits that are covered by the plan.  Your Medicare Advantage plan's MOOP limit can change every year and your Medicare plan may have a higher MOOP limit for out-of-network care (or your plan may exclude out-of-network care from the MOOP limit, meaning your out-of-network coverage costs can have no limit).  You can check your plan documentation to learn more about your MOOP and out-of-network MOOP (if any).  For example, you may read:
"In-network maximum out-of-pocket amount $6,500

Your costs for covered medical services (such as copays) from network providers count toward your in-network maximum out-of-pocket amount. Your plan premium and your costs for [Medicare Part D] prescription drugs do not count toward your maximum out-of-pocket amount.

Once you have paid $6,500 out-of-pocket for covered Part A and Part B services, you will pay nothing for your covered Part A and Part B services from network providers for the rest of the calendar year.

Combined [in-network and out-of-network] out-of-pocket amount $13,300

Your costs for covered medical services (such as copays) from in-network and out-of-network providers count toward your combined maximum out-of-pocket amount. Your plan premium and costs for outpatient [Medicare Part D] prescription drugs do not count toward your maximum out-of-pocket amount for medical services.

Once you have paid $10,000 out-of-pocket for covered Part A and Part B services, you will pay nothing for your covered Part A and Part B services from network or out-of-network providers for the rest of the calendar year." [emphasis added]

Prior authorization for out-of-network care may affect your MOOP.
You may also find that if your out-of-network healthcare does not receive prior authorization from your Medicare Advantage plan then you may not have the cost included in your annual MOOP limit.  For example, in your Medicare Advantage plan's Evidence of Coverage document, you may read:
“In addition, generally amounts you pay for non-authorized and/or non-plan directed out-of-network services, Non Medicare Covered Services and supplemental benefits such as, but not limited to: Dental, Hearing, Outpatient Blood Services, Over the Counter medications, Transportation and Vision do not count toward your maximum out-of-pocket amount.”
So, in summary, yes, you should be able to use your Medicare Advantage plan as you travel around the country, but you should speak with your Medicare plan before traveling - and if required, seek your plan's prior authorization before accessing any out-of-network healthcare.  You can reach one of your plan's Member Services representative by calling the toll-free number found on your Member ID card or on your plan's documentation.

See the related question
: "If I travel between two states throughout the year (Maine and Florida), is there a Medicare Advantage plan that can provide coverage in both states without additional cost?"

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