Question from Kara: My Primary Care Doctor will no longer be in-network with my Advantage Plan PPO in 2026. Why did that happen and what are my options? 

Answer: Be advised that only independent doctors, those not employed by a hospital or health system, are being removed from your company’s network. 

Let’s start with why. Almost all Advantage Plan companies did not hit their target profit margins, and several operated at a loss in 2024 and 2025, due to the higher cost and utilization of medical care and prescription drugs. Practically every decision these companies make comes down to money. Your current PPO company decided to kick your doctor, and many others including specialists, out of their network because they believe it will help their bottom line. 

Expect smaller networks on Advantage Plans

I want to continue sending this message out to those who have Medicare Advantage Plans or are considering one: Get used to smaller networks in the coming years because what Kara and other are facing will likely become more common, only on a much larger scale in 2027 and beyond. 

2026 still offers plenty of lower priced Advantage Plan HMOs and PPOs with good overall co-pay structures and generous “extras,” while also providing in-network access to Western PA’s four largest health systems, UPMC, AHN, Independence, and WVU, along with independent doctors and hospitals.

However, I’m predicting to get the best value in Advantage Plan in the coming years, people will need to make choices in plans that will only have one or two of those health systems in network. Those who want to keep all four, even just both UPMC and AHN, as well as independent doctors and hospitals, will be forced to pay more for plans that have higher co-pays and fewer “extras.” I foresee a time in the near future when plans with larger networks are going to have premiums from $50 to $100 per month as opposed to the $0 to $30 that we’ve been accustomed to.  

Smaller networks aren’t new

Since 2014, small networks have been the reality for people under 65 who use the Affordable Care Act (ACA), also known as Obamacare, to get their health insurance. Those who reside in Allegheny County are basically forced to choose between using only UPMC or AHN doctors and hospitals exclusively. In other words, those who choose a UPMC plan can only use UPMC providers, and those who choose Highmark, just AHN. Again, I believe this is where we’re headed with Advantage Plans as well. 

Options for those losing network access to their current doctors

What are your options? Kara’s plan is a PPO which means she can use out of network providers under a couple of conditions: A) The provider is willing to accept her insurance. B) Kara is willing to pay a higher cost, 40% of the billable amount of the visit or service. With her current plan, an in-network PCP visit is $0 and a Specialist $25. If Kara were to use an out-of-network doctor, at 40% coinsurance, she can expect to pay around $40 for a PCP, and in the range of $100 for a specialist. 

Choosing another PPO or HMO that still has her doctor still in-network is an option for Kara, and there are even some with her current company that do.

Supplements, Supplements, Supplements!

Another option, and one I’m advising anyone who can pass underwriting to consider, is moving to a Supplement that eliminates networks and the concern of losing access to doctors and hospitals altogether. Those with Supplements can see any medical provider in the country who accepts Medicare Assignment at no additional costs. 

Not only are networks going to shrink with Advantage Plans, but as I’ve been writing about the last few weeks, we’re also going to see higher premiums, co-pays, and Maximum Out of Pocket (MOOP), as well as fewer and less generous “extras.” The march towards plans looking like they did prior to 2019 has begun. I really think it will be wise for many people to move to a Supplement, this AEP, while they can still pass underwriting. Those who want to “wait and see” what plans may look like in 2027 may not be able to move to a Supplement if their health changes between now and then. 

If you have any questions regarding this column or would like to make an appointment for a plan review during the Medicare Annual Election Period, give the office a call, 724-603-3403. Or email me personally, Aaron@GetYourBestPlan.com.