4 Things to Know Before Choosing a Medicare Advantage Plan

Feel more confident about selecting a Medicare plan by keeping several things in mind when shopping around during open enrollment.

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Medicare can be confusing, but it doesn’t have to be. Armed with the right information, you’ll be ready to shop for a plan and choose the right one for you and your needs. As you compare plans, benefits, and prices, it’s important to keep a few key things in mind.

Related: Important Dates to Remember When Shopping for a Medicare Advantage Plan

1. Consider your medications

Many people take one or more medications on a regular basis. It is important to review the drug formulary to make sure the medication(s) you take are covered by the plan and at a copay that makes sense for your budget. If you are thinking about staying with your current plan, you should check your Evidence of Coverage and Annual Notices of Changes document to see if there have been any changes to your medication coverage.

When reviewing a drug formulary, make sure to check:

  • Drug brand names and generics
  • Quantity limits (how much you can get in a specific time period)
  • Prior authorization requirements
  • Limited pharmacy access (some drugs are only available at specific pharmacies)
  • Prescription tiers and the associated costs

There are a lot of tools out there that allow you to shop plans and compare drugs costs between Medicare Advantage and Prescription Drug Plans. Call us or your insurance agent and request a free drug analysis.

2. Find a plan that works for you

Circumstances in life are always changing. What may have been a great plan may not suit your needs anymore. Remember to review your plan and coverage every year. Just like when you shop for any other plan, always keep your eyes out for:

  • Provider and facility network: In-network versus out-of-network. Are your doctors and facilities covered on your current plan? If a provider is out-of-network, it means they don’t participate on your plan. That means if you see them, you may end up responsible for paying for excess charges.
  • Monthly premiums: This is the monthly bill you pay for your insurance coverage.
  • Annual deductible: This is an amount you must pay to doctors and facilities before your plan begins to pay for eligible charges.
  • Out-of-pocket (OOP) maximums: This is the total amount you may pay for services covered by your plan each year. Amounts you pay towards your deductible, coinsurance, and copays apply to your out-of-pocket maximum. Some plans have separate medical and pharmacy deductibles, and some services may not apply to or may exceed the OOP maximum. Out-of-pocket maximums are often overlooked when estimating annual healthcare costs. Depending on the plan you choose, you could end up with a “sky’s the limit” out-of-pocket cost.
  • Copays and coinsurance: With some plans, you may have copayments or coinsurances to pay for doctor services. Most plans have lower copays for primary care providers and higher copays for secondary care providers. Copays are fixed amounts, and coinsurance is usually a percentage of the cost you pay after you reach your deductible.
  • Referral requirements: What if you need to see a specialist? With many plans, a referral from your primary care provider is required before you can seek any specialized care; without that prior approval, you may be responsible for footing the bill.
  • Bonus perks: What options, tools, and services are included on your plan? Find out about gym memberships, wellness reimbursements and discounts, vision and dental, and other extras. Some perks may cost more. Consider things like glasses, eye exams, dental cleanings, and hearing aids. Take a look to see how these bonus perks fit your budget, lifestyle, and needs.

3. Be in good company

Choosing the right plan is hard—wading through the hundreds of insurance companies can be downright exhausting. For starters, there are several categories to consider:

  • Not-for-profit vs. for-profit: Who is the priority—you or shareholders? For-profit companies must return profits to investors while not-for-profits must reinvest their profits back into the plan to benefit members.
  • Local vs. national: Local insurance companies know and likely use the same facilities, doctors, and resources, and they work with them to provide the highest quality services at the most affordable prices. Local companies often employ local representatives who have the local know-how to make sure you get the services you need. National companies may not have that local expertise, but they may have broader coverage with a national footprint.
  • Customer service you deserve: This is a big deal! Can you talk to a local person on the phone? Do you have to wait on hold and jump through a thousand hoops just to be told a generic answer? When you need answers, you need a real person to make things happen for you.

4. Review the star rating

The Centers for Medicare and Medicaid Services (CMS) use a five-star quality rating system to evaluate health plans. The Star Rating can tell you a lot about a company’s customer service, member satisfaction, benefits, and overall quality. Pay attention to those stars. Based on real members’ answers to surveys and questionnaires, companies receive an updated rating annually. These rankings make it easy to weed out less than the best.

What’s next?

You’ve done your homework and you’re ready. If you’ve decided to enroll in a SelectHealth Advantage plan, let’s get to know each other. We would like to chat with you to make sure you understand everything about your soon-to-be plan, network, benefits, and contacts. Call us at 855-442-9940 (TTY: 711) to get started.

Related: 7 Steps to Make Medicare Work Better for You


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