Jane Dotson
TriValley Medical Group accepts several insurance plans, including traditional Medicare and Medicare Advantage Plans. Medicare Advantage Plans are designed to reduce the costs of medical care, resulting in lower out-of-pocket expenses for members. This type of plan often covers doctor visits, hospital charges, preventive care, prescription drugs, routine physicals, and lab tests. TriValley Medical Group also works with Managed Care/HMO plans, where patients must select a physician from their network of healthcare providers prior to their visit. It is recommended that patients contact their insurance providers directly to confirm their specific coverage details and to understand the rules regarding referrals and prior approvals to avoid unexpected costs.
| Characteristics | Values |
|---|---|
| Insurance Types Accepted | Traditional Medicare, Medicare Advantage Plans, Medicaid, Indian Health Services, Veterans Affairs Health Care, TRICARE |
| Medicare Advantage Plan Features | Lower out-of-pocket expenses, 100% coverage for many services after a small copayment, no annual deductible or lifetime maximums |
| Managed Care/HMO Plan Requirements | Contact the number on your insurance card to select a TriValley physician prior to your visit |
| HMO Plan Description | Choose a Primary Care Physician (PCP) from a network of local providers who will refer you to in-network specialists or hospitals |
| Insurers Offering HMO Plans | Aetna, Amerihealth Braven Health, Cigna, Clover Centivo, Horizon Blue Cross Blue Shield of NJ, United HealthCare, and more |
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What You'll Learn
- TriValley Medical Group accepts traditional Medicare and Medicare Advantage Plans
- Medicare Advantage Plans offer lower out-of-pocket expenses
- Patients with Managed Care/HMO plans must select a TriValley physician before their visit
- The No Surprises Act protects consumers from surprise billing for emergency services
- TriValley patients must follow their health plan's rules about referrals and prior approval
TriValley Medical Group accepts traditional Medicare and Medicare Advantage Plans
Medicare Advantage Plans are designed to manage the costs of medical care, resulting in lower out-of-pocket expenses for members compared to other types of medical insurance. Doctor's visits, hospital charges, and many other medical expenses are often covered at 100% after a small copayment. Preventive care, prescription drugs, routine physicals, lab tests, and vision exams are typically covered under Medicare Advantage Plans. These plans do not usually require the payment of an annual deductible and generally have no lifetime maximums.
If you have a Managed Care/HMO plan, you must contact the number on your insurance card to select a TriValley physician before your visit. This step ensures the proper coordination of your care team. With an HMO plan, you must choose a Primary Care Physician (PCP) who will be your first point of contact for healthcare and refer you to in-network specialists or hospitals as needed.
TriValley Medical Group's mission is to ensure patients receive the right care they need. In most cases, your primary care doctor will manage your care, and you may need a referral from them to see outside specialists. Prior approval (authorization) from your medical group or health plan may also be required, and it is important to follow your health plan's rules to avoid paying the full cost of treatment.
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Medicare Advantage Plans offer lower out-of-pocket expenses
TriValley Medical Group accepts traditional Medicare and Medicare Advantage Plans. Medicare Advantage plans are designed to manage the costs of medical care, which means members often enjoy lower out-of-pocket expenses compared to other types of medical insurance.
Medicare Advantage plans are offered by private insurance companies that contract with Medicare. The federal government pays these insurers a set amount per enrollee per month, which varies depending on the enrollee's location, health status, and the plan's estimated costs. This payment covers Medicare Part A and Part B services, and in most cases, insurers also pay for supplemental benefits, reduced cost-sharing, and lower out-of-pocket limits.
Medicare Advantage plans often cover visits to the doctor’s office, hospital charges, preventive care, prescription drugs, routine physicals, lab tests, and vision exams. These plans usually do not require an annual deductible before services are covered and typically have no lifetime maximums.
The out-of-pocket maximum for Medicare Advantage plans in 2025 is $9,350 for in-network expenses and $13,300 for combined in-network and out-of-network expenses. This limit protects enrollees from potential financial hardship in the event of an unexpected medical crisis. It is important to note that Medicare Advantage plans can set their own voluntary out-of-pocket limits, as long as they are lower than the government maximum.
When choosing a Medicare plan, it is crucial to consider the potential out-of-pocket costs. While traditional Medicare does not have an out-of-pocket maximum, Medicare Advantage plans offer this protection, ensuring that enrollees are not financially responsible for costs beyond the maximum threshold.
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Patients with Managed Care/HMO plans must select a TriValley physician before their visit
If you are a patient with a Managed Care/HMO insurance plan, it is important to select a TriValley physician before your visit. This is a necessary step to ensure that your care team is properly coordinated. To do this, simply call the number on your insurance card.
Managed Care/HMO plans require you to choose a Primary Care Physician (PCP) who will be your first point of contact for healthcare. This PCP will refer you to in-network specialists or hospitals when necessary. In most situations, your primary care doctor will manage your care and may need to refer you to an outside specialist. For example, if you have a heart problem, your primary care doctor may refer you to a cardiologist.
At TriValley Medical Group, our mission is to get you to the right place for the care that you need. Once you and your primary care provider decide on a plan of action, we will begin the paperwork. The Authorizations and Referral department will gather your medical and insurance information, which can take up to 72 hours depending on the complexity of your case. This information will then be sent to your medical group for review. For urgent cases, the process can be expedited based on medical necessity and your provider's recommendation.
We recommend that you follow your health plan's rules regarding referrals and prior approvals to avoid unexpected costs. If you have any questions or concerns, you can contact the Authorizations and Referral department at TriValley Internal Medicine Group at any time to check the status of your referral.
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The No Surprises Act protects consumers from surprise billing for emergency services
TriValley Medical Group accepts traditional Medicare and Medicare Advantage Plans. Medicare Advantage plans are offered by private companies that contract with Medicare to provide members with benefits (Part A and usually Part B). Medicare Advantage plans are designed to manage the costs of medical care, resulting in lower out-of-pocket expenses compared to other types of insurance.
If you have a Managed Care/HMO plan, you must select one of their physicians before your visit. With an HMO plan, you must choose a Primary Care Physician (PCP) from a network of healthcare providers who will refer you to in-network specialists or hospitals.
The No Surprises Act (NSA) protects consumers who get coverage through their employer, through the Health Insurance Marketplace, or directly through an individual health plan from surprise billing for emergency services. It bans surprise bills for emergency services, even if they are provided out-of-network and without prior authorization. It also bans out-of-network cost-sharing for emergency and some non-emergency services, meaning you can't be charged more than in-network cost-sharing.
The Act also establishes an independent dispute resolution process for payment disputes between plans and providers. If you are uninsured or decide not to use your insurance, you will get a "good faith" estimate of the cost of your care upfront. If the final bill is at least $400 more than the estimate, you may be able to dispute the charges. The No Surprises Act supplements state surprise billing laws, creating a "floor" for consumer protections against surprise bills from out-of-network providers.
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TriValley patients must follow their health plan's rules about referrals and prior approval
TriValley Medical Group accepts traditional Medicare and Medicare Advantage Plans. Medicare is a federal health insurance program administered by the Centers for Medicare & Medicaid Services (CMS), a division of the U.S. Department of Health and Human Services.
Medicare Advantage plans are designed to manage the costs of medical care, meaning members often have lower out-of-pocket expenses compared to other types of medical insurance. Doctor visits, hospital charges, and many other medical care expenses are often covered at 100% after a small copayment. Generally, preventive care, prescription drugs, routine physicals, and lab tests are covered.
If you have a Managed Care/HMO plan, you must select one of their physicians prior to your visit by calling the number on your insurance card. With an HMO plan, you must choose a Primary Care Physician (PCP) who will refer you to in-network specialists or hospitals when necessary.
TriValley patients must follow their health plans' rules about referrals and prior approval. If you do not follow the rules, you may have to pay the full cost. In most situations, your primary care doctor manages your care and may need to refer you to outside specialists. You may also need prior approval (authorization) for the service from your medical group or health plan. The Authorizations and Referrals department will gather your medical and insurance information, which can take up to 72 hours, and then send it to your medical group for review. The entire process will generally take no more than two weeks for non-urgent cases.
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Frequently asked questions
Tri Valley Medical Center accepts traditional Medicare and Medicare Advantage Plans.
Medicare Advantage plans are designed to manage the costs of medical care, which means members enjoy lower out-of-pocket expenses compared to other types of medical insurance.
If you have a Managed Care/HMO plan, you must contact the number on your insurance card to select a physician from Tri Valley Medical Center prior to your visit.
If you don't have insurance, you will be informed of the cost of your healthcare beforehand. The No Surprises Act also protects consumers from surprise billing for emergency services.
Once you and your primary care provider decide on a plan of action, Tri Valley Medical Center will begin gathering your medical and insurance information. This process can take up to 72 hours.
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