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What questions should I ask before joining a Medicare private health plan?

Question 7 of 9 (use "Last" or "Next" buttons to see more)
Last Update: March 11, 2009

Doctors, Hospitals and Other Health Care Providers
  • Will I be able to use my doctors? Are they in the plan's network and are they taking new patients who have this plan?
  • 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?
  • DoI 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?
    • Physical exams
    • Dental services
    • Vision care
    • Hearing aids

      To learn more about Medicare drug coverage (which is often offered by Medicare private health plans), click on the link in the GO TO box.

  • 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)?

Cost

  • How much is my monthly premium?
  • 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 for brand-name drugs? How much for generic drugs?
  • 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 cancer treatment?
  • Is there an annual out-of-pocket maximum? (After you spend a certain amount will your care be free or very low-cost?) Are all services included in the out-of-pocket maximum?

Service Area

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


Case Examples
Ms. W was involuntarily enrolled in a Medicare private health plan.

Related Questions
What is a formulary?

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GO TO
How do I compare Medicare private drug plans?

What is the 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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