What questions should I ask before joining a Medicare Advantage plan?

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Doctors, Hospitals and Other Health Care Providers

  • 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 providers aren’t in the network, will the health plan still cover my visits if I choose to see them?
  • Do my doctors recommend joining this plan?
  • Which specialists, hospitals, home health agencies and skilled nursing facilities are in the plan's network?

Access to Health Care

  • Who can I choose as my Primary Care Physician (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?
Benefits
  • What extra benefits does the plan offer? What rules do I have to follow to get them?
    • Dental services
    • Vision care
    • Hearing aids

Prescription Drugs

  • Does the plan cover outpatient prescription drugs?
  • Are my prescription drugs on the plan's formulary (list of covered drugs)?
  • Does the plan require that I get prior authorization before my prescription will be covered, or impose other restrictions, like limiting the quantity or requiring that I try a cheaper medication before it will cover a more expensive one?
  • Do I have to pay a deductible before the plan will cover my drugs?
  • 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?

Cost

  • How much is the Medicare Advantage plan's monthly premium?
  • Will I pay a higher premium because of my income? (Starting in 2011, individuals with yearly income above $85,000 and couples with yearly income above $170,000 pay more for both Part B and Part D.)
  • What is the annual out-of-pocket maximum?  (After you spend a certain amount, your care will be free or very low cost).
    • Note: PPOs have different out-of-pocket limits for in-network and out-of-network care. If you’re in a PPO, you should 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 a visit with my PCP or a visit with a specialist?
  • How much will I pay if I use a non-network doctor or hospital?
  • Are there higher copays for certain types of care, such as hospital stays or home health care?

Service Area

  • What service area does the plan cover?
  • What kind of coverage do I have if I travel outside of the service area?

Coordination of Benefits

  • How does the plan work with my current coverage?
  • If I join, would I lose my retiree/employer health coverage?

Related Questions
Can my state give me more rights and protections than federal law regarding Medigap plan enrollment?

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GO TO
How do I compare Medicare private drug plans?

Medicare prescription drug benefit (Part D)

 
LINKS
Joint Commission on the Accreditation of Healthcare Organizations

The National Committee for Quality Assurance (NCQA)

State Health Insurance Assistance Program (SHIP) Directory

 
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