10/08/2026
DID YOU KNOW?
HOW DO INSURANCE COMPANIES DECIDE WHERE TO OFFER MEDICARE ADVANTAGE PLANS?
Many Medicare beneficiaries are surprised to learn that Medicare Advantage insurance companies do not necessarily offer their plans in every county, even when local healthcare providers are willing to participate.
So, how does an insurance company decide where to offer coverage?
1. Insurance Companies Choose Their Service Areas
Private insurance companies, not local healthcare clinics, decide which counties they want to serve through Medicare Advantage plans. These service areas must be approved by the Centers for Medicare & Medicaid Services (CMS).
2. Insurance Companies Evaluate Financial Feasibility
Companies consider factors such as the number of potential members, anticipated healthcare costs, and the financial sustainability of offering plans in a particular county.
In rural communities with smaller populations, these considerations can influence whether a company chooses to offer coverage.
3. Insurance Companies Must Establish Adequate Healthcare Networks
Before offering many types of Medicare Advantage plans, insurance companies must demonstrate that their provider networks meet federal requirements for access to primary care, specialty services, hospitals, and other healthcare services.
Importantly, a local clinic may already participate with an insurance company, but the company must still satisfy additional network requirements.
4. CMS Reviews and Approves Service Areas
CMS establishes federal requirements and reviews Medicare Advantage organizations' applications. Insurance companies cannot simply begin marketing a new Medicare Advantage plan in a county without the necessary approval.
5. Insurance Companies Can Decide to Leave a County
Even when healthcare providers are available and willing to participate, an insurance company may decide to discontinue offering Medicare Advantage plans in a particular county for business or operational reasons, subject to CMS requirements.
WHAT DOES THIS MEAN FOR OUR RURAL COMMUNITIES?
For residents that we serve and surrounding counties, limited insurance options can create additional challenges in accessing healthcare.
Wayne Community Health Centers supports providing Medicare beneficiaries with meaningful insurance choices and access to local healthcare services.
We believe patients deserve to understand how Medicare Advantage coverage decisions are made and recognize that the availability of these plans involves decisions made by insurance companies and federal regulators, not simply local healthcare providers.
If you are reviewing your Medicare coverage, remember that Original Medicare remains an option, and Medicare Advantage is not the only way to receive Medicare benefits.
Medicare Annual Enrollment: October 15 – December 7
For assistance understanding your options, reach out to WCHC’s outreach and enrollment advisor or visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227).
