Questions to ask before joining a Medicare Advantage Plan

Medicare Advantage Plan overview

When you are choosing between Original Medicare and Medicare Advantage 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, 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 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)?
  • Does my doctor need to get approval from the plan to admit me to a hospital?
  • Do I need a referral from my PCP to see a specialist?

Costs

  • What costs should I expect for my coverage (premiums, deductibles, copayments)?
  • What is the annual maximum out-of-pocket (MOOP) cost?
    • Note: PPOs have different out-of-pocket limits for in-network and out-of-network 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)?
  • How much is my copayment for services I regularly receive, such as PCP or specialist care?
  • How much will I pay if I visit an out-of-network provider or facility?
  • Are there higher copays for certain types of care, such as hospital stays or home health care?

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 prescription drugs?
  • Are my prescriptions on the plan’s formulary?
  • Does the plan impose any coverage restrictions?
  • 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?
  • 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