When you are choosing between Original Medicare and Medicare Advantage or between Medicare Advantage Plans, here are some questions to keep in mind.
Providers, hospitals, and other facilities
- Will I be able to use my doctors? Are they in the plan’s network?
- Do doctors and providers I want to see in the future take new patients who have this plan?
- If my providers are not in-network, will the plan still cover my visits?
- Which specialists, hospitals, home health agencies, and skilled nursing facilities are in the plan’s network?
Access to health care
- What is the service area for the plan?
- Do I have any coverage for care received outside the service area?
- Who can I choose as my Primary Care Provider (PCP)?
- Does my doctor need to get approval from the plan to admit me to a hospital?
- Do I need a referral from my PCP to see a specialist?
Costs
- What costs should I expect for my coverage (premiums, deductibles, copayments)?
- What is the annual maximum out-of-pocket (MOOP) cost?
- Note: PPOs have different out-of-pocket limits for in-network and out-of-network care. If you’re considering a PPO, find out what the different out-of-pocket limits are for in-network and out-of-network care.
- How much will I have to pay out of pocket before coverage starts (what is the deductible)?
- How much is my copayment for services I regularly receive, such as PCP or specialist care?
- How much will I pay if I visit an out-of-network provider or facility?
- Are there higher copays for certain types of care, such as hospital stays or home health care?
Benefits
- Does the plan cover any services that Original Medicare does not?
- Dental services
- Vision care
- Hearing aids
- Are there any rules or restrictions I should be aware of when accessing these benefits?
Prescription drugs
- Does the plan cover outpatient prescription drugs?
- Are my prescriptions on the plan’s formulary?
- Does the plan impose any coverage restrictions?
- What costs should I expect to pay for my drug coverage (premiums, deductibles, copayments)?
- How much will I have to pay for brand-name drugs? How much for generic drugs?
- What will I pay for my drugs during the coverage gap?
- Will I be able to use my pharmacy? Can I get my drugs through mail order?
- Will the plan cover my prescriptions when I travel?
Coordination of benefits
- How does the plan work with my current coverage?
- If I join, would I lose my job-based insurance or retiree coverage?