CoxHealth, Mercy and Medicare Advantage Provider Networks in Springfield

What “Accepts Medicare” Means

The phrase “accepts Medicare” can describe several different situations.

A provider may:

• Accept Original Medicare
• Participate in certain Medicare Advantage networks
• Participate at one location but not another
• Accept some products from an insurance company but not every plan
• Be leaving or joining a network for the upcoming year

This means a provider’s office saying, “Yes, we take Medicare,” may not answer the complete question.

The complete plan name matters. Insurance companies can offer several plans using different networks, rules and service areas.

Original Medicare

With Original Medicare, you can generally receive covered services from any doctor or facility in the United States that accepts Medicare.

Original Medicare does not use a local provider network in the same manner as most Medicare Advantage plans.

Before receiving care, ask whether the provider:

• Accepts Medicare
• Accepts Medicare assignment
• Is accepting new Medicare patients
• Provides the specific service you need

What is Medicare assignment?

A provider who accepts assignment agrees to accept the Medicare-approved amount as full payment for a covered service. You remain responsible for applicable Medicare deductibles and coinsurance unless other coverage pays those amounts.

Some providers may accept Medicare patients without accepting assignment for every service. Different cost rules may apply in those circumstances.

You can search for Medicare-participating healthcare providers through Medicare Care Compare.

Medicare Advantage Networks

Medicare Advantage plans provide Medicare Part A and Part B benefits through private insurance companies approved by Medicare.

These plans may use provider networks. The effect of using an out-of-network provider depends on the plan type and circumstances.

HMO plans

A Health Maintenance Organization plan generally requires routine care from participating network providers, except for emergency care, urgently needed care and certain other protected situations.

Going outside the network for non-emergency care may leave you responsible for the entire bill unless the plan authorizes the care.

PPO plans

A Preferred Provider Organization plan may allow covered services from out-of-network providers, but the beneficiary will generally pay more.

An out-of-network provider may also decline to treat a plan member except where other requirements apply.

Other plan types

Other types of Medicare Advantage plans may use different provider-access rules. Compare the exact HMO, PPO and HMO-POS network rules rather than assuming all Medicare Advantage coverage works the same way.

CoxHealth

CoxHealth operates hospitals, clinics and provider practices throughout Springfield and southwest Missouri. CoxHealth also has its own Medicare Advantage coverage offered through Cox HealthPlans.

In addition to its own plan, CoxHealth may participate with certain Medicare Advantage plans offered by other insurance companies. Participation can vary by plan, provider, facility, location and coverage year.

If you want to continue receiving care through CoxHealth, prepare a list containing:

• Your CoxHealth primary care physician
• Every CoxHealth specialist you see
• Your preferred CoxHealth hospital or outpatient facility
• Therapy or rehabilitation providers
• Laboratory and imaging locations
• Medical equipment suppliers

Then compare each provider and facility against the exact Medicare Advantage plan being considered. Do not assume that every insurance plan listing “CoxHealth” uses the same network or covers every CoxHealth-affiliated provider.

Current provider and insurance information is available through the CoxHealth insurance provider page.

Individual Doctors and Locations

A hospital appearing in a network does not automatically prove that every doctor practicing there participates.

Physicians working inside the same facility may belong to different medical groups or billing organizations.

This can be especially important for:

• Anesthesiologists
• Radiologists
• Pathologists
• Emergency physicians
• Surgeons
• Behavioral healthcare providers
• Independent specialists

When planning a procedure, ask about the facility and the professionals who may bill separately.

Verify the exact location

A physician may work at multiple Springfield-area locations. One office could participate in a network while another location uses a different billing arrangement.

Record the full address of the location you use—not only the provider’s name.

Referrals and Prior Authorization

Being in-network does not guarantee that every service will be covered automatically.

A Medicare Advantage plan may require:

• A referral from a primary care provider
• Prior authorization before a procedure
• Use of a specific facility
• Documentation showing medical necessity
• Step therapy for certain medications
• Use of participating equipment suppliers

Ask your provider who is responsible for requesting authorization and confirm approval before receiving non-emergency services. If specialist access is part of your comparison, review the Springfield Medicare specialist and referral guide.

Emergency and Out-of-Network Care

Medicare Advantage plans must cover emergency and urgently needed care according to Medicare requirements, including when you are outside the plan’s local service area.

However, follow-up and routine care after an emergency may be subject to network or authorization requirements.

If you receive emergency treatment:

• Present your current insurance card
• Notify the plan when required
• Ask about follow-up coverage
• Keep discharge and billing records
• Confirm where continued care should occur

Do not use emergency coverage as a substitute for understanding the rules governing routine out-of-network care.

Pharmacy Networks

Provider networks are only part of the picture. Medicare Advantage plans with drug coverage and standalone Part D plans also use pharmacy networks.

A pharmacy may be:

• In-network and preferred
• In-network but standard
• Out-of-network
• Available only under limited circumstances

A preferred pharmacy may offer lower plan-negotiated cost-sharing than a standard network pharmacy.

Before selecting prescription coverage, compare:

• Your preferred Springfield pharmacy
• Other convenient nearby pharmacies
• Mail-order options
• Medication tiers
• Deductibles and copays
• Prior authorization and quantity limits

Learn more about Medicare Part D →

Provider Verification Checklist

Use more than one source whenever possible.

Why use multiple sources?

Provider directories can contain errors or become outdated. Provider-office employees may also recognize an insurance company’s name without knowing the network for every individual plan.

If one source says the provider participates and another says it does not, resolve the disagreement before making a coverage decision.

What to Bring to a Review

A provider-focused Medicare comparison works best when you bring accurate information.

Prepare:

• Your Medicare card
• Current insurance card
• Primary care physician’s full name and address
• Each specialist’s full name and address
• Preferred hospitals and facilities
• Physical therapy or rehabilitation providers
• Medical equipment suppliers
• Complete prescription list
• Preferred pharmacies
• Planned surgeries or ongoing treatments

This information makes it possible to compare coverage using your actual healthcare needs rather than a generic provider list.