When you are choosing between Original Medicare Original Medicare, also known as Traditional Medicare, is the fee-for-service health insurance program offered through the federal government, which pays providers directly for the services you receive. Almost all doctors and hospitals in the U.S. accept Original Medicare. and Medicare Advantage Medicare Advantage, also known as Part C, Medicare Private Health Plan, or Medicare Managed Care Plan, allows you to get Medicare coverage from a private health plan that contracts with the federal government. All Medicare Advantage Plans must offer at least the same benefits as Original Medicare (Part A and Part B), but can do so with different rules, costs, and coverage restrictions. Plans typically offer Part D drug coverage as part of Medicare Advantage benefits. Medicare Advantage Plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS) plans, Special Needs Plans (SNPs), and Medicare Medical Savings Accounts (MSAs). 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 In-network means part of a private health plan’s network of providers. If you use doctors, hospitals, pharmacies, home health agencies, skilled nursing facilities, and durable medical equipment suppliers that are in your Medicare Advantage Plan or Part D plan’s network, you will generally pay less than if you go to out-of-network providers. , 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 The service area is the geographic area where a Medicare Advantage Plan or Part D plan provides medical services to its members. In many plans, the service area is where your network of providers is located. 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) The primary care provider (PCP) is the doctor or other health care worker who manages your health care and gives you a referral to consult a specialist if you need it. In Medicare Advantage, many Health Maintenance Organizations (HMOs) require you to select a PCP and get their permission or referral before seeing a specialist. Preferred Provider Organizations (PPOs) and Private Fee-for-Service (PFFS) plans do not have this requirement. ?
- Does my doctor need to get approval from the plan to admit me to a hospital?
- Do I need a referral Referrals are authorizations that Medicare Advantage Plans usually require for services not provided by your primary care provider (PCP). For example, Health Maintenance Organizations (HMOs) generally require you to get a referral from your PCP in order to see a specialist or get an eye exam. from my PCP to see a specialist A specialist is a doctor who specializes in treating only a certain part of the body or a certain condition. For instance, a cardiologist only treats people with heart problems. ?
Costs
- What costs should I expect for my coverage (premiums, deductibles, copayments)?
- What is the annual
maximum out-of-pocket (MOOP)
The maximum out-of-pocket (MOOP) is an annual limit on your out-of-pocket costs for Medicare Advantage Plans. Once you reach this amount, you will not owe cost-sharing for Part A or Part B covered services for the remainder of the year. All Medicare Advantage Plans are required to set a maximum out-of-pocket.
cost?
- Note: PPOs have different out-of-pocket limits for in-network and out-of-network Out-of-network means not part of a private health plan’s network of health care providers. If you use doctors, hospitals, or pharmacies that are not in your Medicare Advantage Plan or Part D plan’s network, you will likely have to pay the full cost out of pocket for the services you received. 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 The deductible is the amount you must pay for health care expenses before your health insurance begins to pay. Deductible amounts can change every year. )?
- How much is my copayment A copayment, also known as a copay, is a set amount you are required to pay for each medical service you receive (like $35 for a doctor’s visit). for services I regularly receive, such as PCP or specialist care?
- How much will I pay if I visit an out-of-network provider See Health Care Provider. or facility?
- Are there higher copays for certain types of care, such as hospital stays or home health care Home health care is care provided at home to treat an illness or injury. Medicare will only cover home health care if you are homebound and have a need for skilled care, including skilled nursing and/or skilled therapy services. ?
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 An outpatient is a patient who has not been formally admitted into the hospital as an inpatient. Most outpatient care is covered under Medicare Part B (medical insurance). prescription drugs?
- Are my prescriptions on the plan’s formulary The formulary is the list of prescription drugs covered by a Part D plan or Medicare Advantage Plan. If your drug is not on the formulary, you may have to request an exception, file an appeal, or pay out of pocket. ?
- Does the plan impose any coverage restrictions Coverage restrictions, also called Utilization Management Tools or formulary restrictions, are restrictions that a health or drug plan may place on certain covered services to limit their usage. Coverage restrictions include prior authorization, quantity limits, and step therapy. ?
- 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 The coverage gap, also known as the Medicare Part D donut hole, is the phase of Part D coverage after your initial coverage period. As a result of the Affordable Care Act (ACA), the coverage gap was phased out in 2020. Your drug costs may still change when you enter the coverage gap, after your initial coverage period, but you will pay no more than 25% of the cost of your drugs in 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?