What type of services does a beneficiary generally have to pay more for if they go out-of-network?

When a beneficiary opts to use out-of-network services under a Medicare Advantage plan, they typically face higher costs for non-emergent eligible services. This is because Medicare Advantage plans often have specific networks of providers with whom they have negotiated lower payment rates, and going outside these networks can result in higher out-of-pocket expenses.

Non-emergent services refer to medical care that is necessary but not immediately urgent, so beneficiaries have more options and flexibility in choosing providers. However, using an out-of-network provider for these types of services usually means that the beneficiary will be responsible for a greater portion of the bill. In contrast, emergency services are often covered at the same rates regardless of provider network status to ensure beneficiaries receive immediate care when needed. Preventive services are also typically covered without cost-sharing when obtained from in-network providers. Similarly, many diagnostic tests might be subject to different cost-sharing requirements based on network participation, but the significant increase in costs is most notable for those non-emergent eligible services sought outside the network.