Key Takeaways

• Before enrolling in a Medicare Advantage plan, make sure you understand coverage details, costs, and provider networks to avoid unexpected surprises.

• Comparing plans and asking the right questions can help you find a plan that aligns with your healthcare needs and budget.

Are You Comfortable with the Network Restrictions?

One of the biggest differences between Medicare Advantage and Original Medicare is provider networks. Unlike Original Medicare, which allows you to see any doctor or specialist who accepts Medicare, Medicare Advantage plans often have restrictive networks.

• Do you have preferred doctors or specialists? If so, check whether they are in-network.

• What happens if you travel? Some plans only provide coverage in specific regions, while others may offer nationwide coverage.

• Are referrals required? Many Medicare Advantage plans require you to get referrals before seeing a specialist, adding an extra step to your care.

If having flexibility is a priority, consider how network restrictions could impact your healthcare choices.

What Are the Out-of-Pocket Costs?

While Medicare Advantage plans have an annual out-of-pocket maximum, costs can still vary depending on the plan’s structure. Be sure to ask:

• What is the plan’s deductible? Some plans require you to pay a deductible before coverage kicks in.

• What are the copayments and coinsurance? These costs can add up quickly, especially for frequent doctor visits or hospital stays.

• What is the out-of-pocket maximum? This is the most you will have to pay for covered services in a given year.

Understanding these costs can help you budget for healthcare expenses and avoid unexpected bills.

Does the Plan Cover Your Prescription Medications?

Prescription drug coverage varies significantly between Medicare Advantage plans. Each plan has its own formulary, or list of covered drugs. When evaluating plans, ask:

• Are my prescriptions covered? Check the plan’s formulary to ensure your medications are included.

• What tier are my drugs in? Many plans categorize drugs into tiers, with lower-tier drugs being more affordable than higher-tier ones.

• Does the plan have a preferred pharmacy network? Some plans offer lower prices if you use certain pharmacies.

Since formularies can change yearly, review your plan’s drug coverage during each Open Enrollment period.

What Additional Benefits Are Included?

Medicare Advantage plans often include benefits beyond what Original Medicare offers. However, not all plans provide the same perks. Consider asking:

• Does the plan include vision, dental, or hearing coverage? These are common additional benefits, but coverage levels vary.

• Are there wellness programs or fitness memberships? Some plans offer incentives for maintaining an active lifestyle.

• Is transportation assistance available? If you need help getting to medical appointments, check if the plan provides ride services.

While extra benefits can be appealing, make sure they align with your healthcare needs.

How Does the Plan Handle Emergency and Urgent Care?

Emergencies can happen at any time, so it’s important to know how your Medicare Advantage plan covers urgent and emergency care. Key questions include:

• Will I be covered if I need emergency care outside my service area? Some plans offer nationwide emergency coverage, while others may not.

• Are urgent care visits covered at the same rate as doctor visits? Copayments for urgent care can vary depending on the plan.

• What happens if I need hospitalization? Check if there are additional costs or restrictions on hospital stays.

Having a clear understanding of emergency coverage ensures you’re prepared for unexpected medical situations.

How Does the Plan Compare to Original Medicare?

Medicare Advantage offers a different structure than Original Medicare, but it’s not the best fit for everyone. Before enrolling, ask yourself:

• Do I prefer the flexibility of Original Medicare or the all-in-one nature of Medicare Advantage?

• Am I comfortable with network restrictions, or do I want to see any doctor who accepts Medicare?

• Are the extra benefits worth any potential trade-offs?

If you’re unsure, it may be worth comparing both options to determine which better fits your healthcare needs.

When Can You Change Plans If You’re Unsatisfied?

Medicare Advantage plans aren’t permanent commitments, but switching isn’t always straightforward. Understanding enrollment periods is crucial:

• Annual Enrollment Period (AEP): Runs from October 15 to December 7 each year. You can switch from one Medicare Advantage plan to another or return to Original Medicare.

• Medicare Advantage Open Enrollment Period: From January 1 to March 31, you can switch Medicare Advantage plans or return to Original Medicare, but you can only make one change.

• Special Enrollment Periods (SEPs): If you experience certain life events, like moving to a new area or losing employer coverage, you may qualify for a Special Enrollment Period.

Knowing your options for switching ensures you’re not locked into a plan that doesn’t meet your needs.

Is the Plan’s Star Rating Satisfactory?

Medicare rates Medicare Advantage plans based on a 5-star system, with 5 stars being the highest. These ratings reflect quality and customer satisfaction. When comparing plans:

• Look for higher-rated plans. A plan with a 4-star or 5-star rating may offer better service and fewer issues.

• Consider customer reviews. While star ratings are helpful, researching member experiences can provide additional insights.

• Check for consistent performance. If a plan’s rating has dropped in recent years, it may indicate declining quality.

A higher-rated plan can lead to better service and fewer hassles.

Will the Plan Still Meet Your Needs Next Year?

Medicare Advantage plans change annually, so even if you’re satisfied now, it’s important to review your plan during Open Enrollment. Ask yourself:

• Are my doctors still in-network? Provider networks can shift, affecting access to care.

• Has my medication coverage changed? Formularies and costs can vary year to year.

• Have the costs or benefits changed? Compare plan changes to ensure they still align with your needs.

Staying informed helps you avoid unexpected surprises and maintain the best possible coverage.

Make an Informed Choice for Your Healthcare

Choosing a Medicare Advantage plan is a big decision that impacts your healthcare and budget. Asking the right questions before enrolling helps you avoid costly mistakes and ensures your plan aligns with your health needs. Whether it’s network restrictions, prescription coverage, or plan benefits, understanding these details puts you in control of your Medicare choices.