Do Medicare Advantage Plans Cover Out-of-State?

Medicare Advantage plans, also known as Part C, are health plans offered by private companies that contract with Medicare to provide your Part A and Part B benefits. These plans often include prescription drug coverage (Part D) and may offer additional benefits not covered by Original Medicare, such as vision, dental, and hearing services. Understanding their coverage when you are outside your plan’s service area, especially across state lines, involves important distinctions. Medicare Advantage plans provide coverage for out-of-state care, but the extent varies significantly depending on the type of care needed and your specific plan.

Coverage for Emergency and Urgently Needed Care

All Medicare Advantage plans are required to cover emergency and urgently needed care anywhere in the United States, regardless of whether the provider is in your plan’s network. An “emergency medical condition” is a sudden illness, injury, or worsening of a chronic condition that you reasonably believe could be dangerous to your health if not treated immediately. This type of care demands prompt medical attention to prevent serious harm.

“Urgently needed care” refers to services for an unforeseen illness or injury that is not life-threatening but requires prompt medical attention to prevent serious deterioration of your health. For example, if you develop a severe flu or have a minor injury like a cut requiring stitches while traveling, this would typically fall under urgently needed care. For both emergency and urgently needed care, prior authorization is generally not required, ensuring you can receive immediate treatment without delay. You will still be responsible for any applicable copayments or coinsurance as outlined by your plan.

Coverage for Non-Emergency Care When Traveling

Coverage for non-emergency care when temporarily traveling out-of-state varies most based on plan structure. Many plans have specific networks limited to certain geographic areas, meaning services received outside these networks may not be covered or could incur higher costs.

Health Maintenance Organization (HMO) Plans

HMO plans typically limit coverage to doctors and hospitals within their network, except for emergency or urgently needed care. If you have an HMO plan, non-emergency care received outside your plan’s service area will generally not be covered, or coverage will be very limited. Some HMO plans may offer a “point-of-service” option, allowing for out-of-network care at a higher cost, but this is not universal. Referrals from a primary care provider are often required to see specialists within HMO networks.

Preferred Provider Organization (PPO) Plans

PPO plans offer more flexibility, allowing you to see out-of-network providers for non-emergency care, though you will typically pay more in copayments or coinsurance. Some PPO plans may even have multi-state networks, which can be beneficial for frequent travelers. Before seeking out-of-network care, contact your plan to confirm coverage and inquire about any necessary prior authorizations.

Private Fee-for-Service (PFFS) Plans

PFFS plans operate differently, allowing you to see any Medicare-approved provider who agrees to the plan’s terms and conditions for payment. These plans offer flexibility as they do not typically restrict you to a network. However, the provider must agree to accept the plan’s payment terms before each visit. While some PFFS plans have networks, you may pay more if you choose an out-of-network provider. Prior authorization requirements also apply to PFFS plans for certain services.

Coverage When Moving to a New State

Medicare Advantage plans are generally tied to specific service areas, typically defined by counties or states. If you permanently move outside your Medicare Advantage plan’s service area, you will need to change your plan. Moving to a new location outside your current plan’s service area triggers a Special Enrollment Period (SEP).

This SEP provides a specific window to switch to a new Medicare Advantage plan available in your new area, or to return to Original Medicare and enroll in a Part D prescription drug plan. If you notify your current plan before you move, your SEP typically begins the month before your move and continues for two full months after. If you have already moved, the SEP generally starts the month you inform your insurance carrier and lasts for two additional months.

Understanding Your Plan’s Specific Rules

Consult your plan’s official documents to understand your Medicare Advantage plan’s out-of-state coverage. The Evidence of Coverage (EOC) document, sent annually, provides comprehensive details about what your plan covers, your costs, and specific rules regarding out-of-area care. This document outlines cost differences for in-network versus out-of-network providers and any prior authorization requirements. You can also contact your plan’s member services department using the phone number on your member identification card. Ask specific questions about coverage for emergency, urgently needed, and non-emergency care when traveling or if you plan to move. Carrying your plan ID card is recommended, as it contains essential contact information and policy details necessary for receiving care away from home.