Those days are long gone. In recent years, the Medicare marketplace has exploded with choices. Wedgwood and View Ridge residents making these decisions or helping senior family members and friends sift through their options are likely well aware the deadline for selecting coverage for 2016 is fast approaching—you have to make your decisions by Dec. 7.
How do you decide which plan best meets your health care needs, preferences and budget? Here are 7 things to consider.
1. Decide how much health care coverage you want.
If you’re only looking for basic, no-frills coverage, Original Medicare takes care of that. It’s the combination of Medicare Part A (hospital insurance) and Part B (medical insurance). To get help paying for prescription medications, you’ll also need to enroll in a Part D (prescription drug) plan. A Medigap (supplemental) plan is another way to help pay for out-of-pocket expenses that aren’t covered by Original Medicare.
Medicare Advantage plans, also known as Medicare Part C, combine Parts A and B, and often Part D. These plans are an alternative to Original Medicare and may include vision, hearing and dental benefits, as well as health and wellness programs that aren’t offered by Original Medicare.
Even if you don’t use many health care services or prescription medications at the moment, keep in mind that even the healthiest person can experience an unexpected illness or accident, and costs can add up fast. Prepare for the unknown as you choose a plan, just in case.
2. Review plan costs.
Look carefully at the costs of each plan, including premiums, deductibles, copays and coinsurance. Then look a little further. How much will you pay for X-rays, outpatient surgery, inpatient hospital care, and other services you may need? Is there a yearly limit on what you pay out-of-pocket? What makes the most sense given your health and financial situation?
3. Find out if your doctors are on the plan’s network.
With Original Medicare, you can see any doctor who accepts Medicare. With most Medicare Advantage plans, you’ll need to use doctors, hospitals, and other facilities in the plan’s network. If you’re considering a Medicare Advantage plan, check the provider directory to see if your doctor is in the plan’s network, or consider whether you’re willing to switch doctors. Also find out if you can see a non-network doctor if you choose, and how much it will cost.
4. Check out prescription drug coverage.
Each health plan that offers prescription drug coverage will include a drug formulary, which is the list of medications the plan covers. Are the medications you’re currently taking on the list? How much will you pay for brand-name drugs, and how much for generic drugs? Does the plan require that you get prior authorization, or meet other requirements, before your medications are covered? And are network pharmacies conveniently located for you?
5. Notice if extra benefits are included.
Check to see if the plan provides fitness or dental benefits, vision care, or hearing-aid coverage. You won’t find that coverage with Original Medicare, but it’s often included as part of Medicare Advantage plans.
6. Consider what’s covered when you travel.
With Original Medicare, you can travel anywhere in the U.S. and its territories and get the medical care you need from almost any doctor or hospital. Medicare Advantage plans may not cover your care in the U.S. outside of the plan’s service area, with the exception of emergency care. Both Original Medicare and Medicare Advantage plans must cover medical care outside the U.S. in a few, limited instances. Also, some supplemental insurance, like Medigap plans, provide coverage for foreign travel. Check each plan carefully to see what rules and costs apply.
7. Check the plan’s quality rating.
The Centers for Medicare & Medicaid Services evaluates the quality of Medicare Advantage plans every year and their ratings give you an apples-to-apples way to compare plans. A 5-star rating indicates the highest rated plan, and a 4-star rating means an above-average plan. You’ll find the most up-to-date star ratings on the Medicare Plan Finder tool at www.medicare.gov/find-a-plan or you can call 1-800-MEDICARE.
Dr. Marc Mora is chief medical officer at Group Health. He received his Doctor of Medicine (M.D.) degree from the University of California – San Francisco School of Medicine. For more information about what the different types of Medicare plans do and don’t include, visit www.medicare.ghc.org/understanding-medicare.page.