How to Choose A Medicare Plan

Since you’re limited as to when you can leave your current plan or change to a new plan, the importance of your decision regarding the coverage you choose when you do have an enrollment period can’t be understated.

When you begin to “shop” for a new plan, or a plan for a first time, get a list together of:

1. Who your doctors are and how often you visit them

2. What medicines you take and how often (if you need drug coverage)

3. What additional medical services you use and how often

4. What other benefits are important to you (vision, dental, gym benefit, etc.)

5. What your health outlook is for the year (Planning major surgery? Have a medical  condition that’s getting worse?)

Once you have that list together, consider these 7 simple, yet important, things when comparing plans and choosing your coverage:

1. Are all of my doctors in the plan’s provider network? If not, are the benefits that much better than what you currently have to make it worth switching doctors? Sometimes the cost savings are significant enough that you may want to consider switching doctors. This is particularly true if the doctor not in that plan’s network is a specialist you don’t see often and the plan has other reputable specialists in their network that could be a replacement you’re comfortable with.

2. Are all of my medicines covered? If you’re considering a plan with Part D coverage, be sure to check the plan’s formulary to make sure all of the medicines you take are covered and covered with a copay you can afford, especially if it’s a medicine you take often. If one of your medicines isn’t covered, maybe there’s a generic version that you could switch to. If you are considering switching to a covered generic or alternative, be sure to consult the doctor that prescribes you that medicine on whether it would be appropriate to switch to another version. Not only are drug copays important to consider, but so is the drug/Part D deductible- the amount you must pay before the plan starts covering your medicines. Sometimes a plan may have very low drug copays but a high deductible, or vice-versa. Depending on the combination of copay and deductible, you could come out better on one plan where your drug copays are higher than another plan’s, just because the deductible is lower.

3. What are the copays for the services I use most often? You should also consider the copays for services you use often, such as Primary Care Physician (PCP) visits, Specialist visits, X-rays, ER visits, etc. in choosing a plan. When you sit down to compare plans think to yourself, “what types of services do I use, and how often do I use them?” For example, if you don’t go to a Podiatrist or don’t foresee entering a Skilled Nursing Facility, those copays probably shouldn’t be a factor in choosing a plan, but if you do see a Chiropractor every month maybe that one is. Don’t be distracted by attractive benefits that you’ll never utilize at the sake of accepting benefits with higher copays for services you use often.

4. Does the plan require a referral to see a Specialist? Let’s say Plan A has a $25 PCP copay and a $40 Specialist copay. Plan B also has a $25 PCP copay, but the Specialist copay is only $30. Sounds great, right? Well, not necessarily if Plan B requires you to first get a referral from your PCP to see that Specialist. If that’s the case, then that would make the cost for that Specialist visit on Plan B actually $55 total, not $40, since you would have to pay the $25 PCP copay in addition to the $30 Specialist copay. It could also mean you would need to make two different trips to two different doctor’s offices. Since Specialist visits are pretty common for most members this is definitely a factor to keep in mind.

5.  What’s the monthly premium? This is usually what sticks out most in a plan- how much you’ll have to pay every month for coverage, regardless of whether you’re using any services that month the plan offers. Lower premiums can certainly be better, but sometimes a higher monthly premium may mean richer benefits, such as lower copays, and the cost-savings on a lower copay could make the higher premium worth it. However, sometimes a high monthly premium can be deceptive. Say you’re looking for a “Cadillac plan” with a high monthly premium but really low copays on every service. That could be great, unless of course you don’t utilize those services often enough to warrant the high premium.  Sure, a $5 PCP copay is fantastic- but if you only see your PCP once or twice a year and don’t receive much care beyond that, is it really worth a premium $100 or more a month over another plan with a slightly higher PCP copay?

6. Does the plan offer emergency coverage outside of its network? If you travel often to another region or even another country and find yourself out of network, would the plan cover emergency care if you happen need it? Depending on your lifestyle and frequency of travel, this could be something you may want to consider.

7.  What do other people think of the plan and how is it rated? All things being equal, does Plan A or Plan B have a better reputation among its members? Ask a friend that’s a member for their experience. Is one plan known for having first-class customer service and another, well, not so much? Another great way to assess a plan’s reputation is through its Medicare Star Ratings. Plans are accessed each year by the Centers for Medicare and Medicaid Services (CMS) through a variety of Part A, B, and D measures, including member experience. Plans are then ranked on a 5-star scale based on the outcome of these measures. The more the stars, the better the plan’s reputation is. You can view plan Star Ratings any time