Dear Marci,

I’ve had Original Medicare for a few years, but I’m planning to join a Medicare Advantage Plan during Fall Open Enrollment this year. How should I choose a Medicare Advantage Plan when there are so many options?

-Rhonda (Spring, TX)

Dear Rhonda,

It’s important to choose a Medicare Advantage Plan that fits your unique needs. Even if your friend or family member loves their Medicare Advantage Plan, it might not work well for you. There are numerous questions you can ask about a plan to determine if it would be a good fit for you, and you can find those below.

You may find it helpful to use Medicare’s Plan Finder tool to learn about the plans available to you. You can even call 1-800-MEDICARE (1-800-633-4227) to request their help with comparing these plans over the phone. Before enrolling in a plan, though, it is a good idea to call the plan directly to confirm what you have learned about it.

You can ask yourself the following questions before choosing a Medicare Advantage Plan:

  • How much are the premium, deductible, and coinsurance/copay amounts?
  • What is the annual maximum out-of-pocket cost for the plan? This amount may be high but can help protect you if you have expensive health care costs.
  • What service area does the plan cover?
  • Are my doctors and hospitals in the plan’s network?
  • What are the rules I have to follow to access health care services and my drugs?
  • Does the plan cover additional health care benefits that are not covered by Original Medicare?
  • How will this plan affect any additional coverage I may have?
  • What is the plan’s star rating?

Medicare Advantage Plans usually include prescription drug coverage. You should also consider these questions when choosing a Medicare Advantage Plan to make sure that the prescription drug coverage that the plan offers meets your needs:

  • Does the plan cover all the medications I take?
  • Does the plan have restrictions on my drugs (i.e. prior authorization, step therapy, or quantity limits?)
    • Prior authorization means that you must get approval from your Part D plan before the plan will pay for the drug.
    • Step therapy means that your plan requires you to try a cheaper version of your drug before it will cover the more expensive one.
    • Quantity limits restrict the quantity of a drug you can get per prescription fill, such as 30 pills of Drug X per month.
  • How much will I pay for monthly premiums and the annual deductible?
  • How much will I pay at the pharmacy (copay/coinsurance) for each drug I take?
  • Is my pharmacy in the plan’s preferred network? You pay the least if you used preferred network pharmacies.
  • Can I fill my prescriptions by mail order?
  • If I have retiree coverage, will the Medicare drug plan work with this coverage?
  • What is the plan’s star rating?

Remember that Fall Open Enrollment runs from October 15 through December 7 each year. During this time, you can make changes to your health insurance coverage, including adding, dropping, or changing your Medicare coverage. When you are ready to enroll in a new Medicare Advantage Plan, you can call 1-800-MEDICARE (800-633-4227) to make the change.

Finally, note that enrollment rules for Medigaps are different. If you later wish to switch from Medicare Advantage to Original Medicare with a Medigap, you may not have the right to purchase a Medigap. There are only a few specific protected times to purchase a Medigap under federal rules, but your state may offer additional rights. To determine whether you could make the switch back to Original Medicare with a Medigap, I would encourage you to reach out to your State Health Insurance Assistance Program (SHIP), as they will be familiar with the Medigap rules in your state. 


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