Which statement best describes how MA plans determine member access to care within a network, including referral and prior authorization requirements?

• A. Plans require use of in-network providers, may require referrals for specialists, and use prior authorization for certain services or medications.
• B. Plans allow any provider regardless of network without authorization.
• C. Members can always receive care outside the network with no restrictions.
• D. Referrals are only required for primary care visits.

Answer: (A)

Medicare Advantage plans use a defined network of providers and manage access through that network. To get the most coverage, members typically must use in-network providers; care from out-of-network providers is usually restricted or not covered, except in emergencies. Within that network, plans often require referrals to see specialists, meaning a primary care physician must authorize a specialist visit to ensure it’s medically necessary within the plan’s rules. They also commonly require prior authorization for certain services or prescription drugs, so the plan approves the service or medication before it will be covered. This combination—network-based access, referrals for specialty care, and prior authorization for specific services or drugs—is how access is determined in MA plans. The other statements describe unrestricted access or no authorization, which doesn't reflect how MA plans set limits and control costs.