As Annual Enrollment for Medicare Advantage and Prescription Drug plans approaches, it is time for Medicare beneficiaries to take stock of their current plans to determine if a change would benefit them.  Plan members should be receiving their Annual Notice of Changes in the mail to see what modifications (if any) are being made for 2023. But with the influx of new Medicare Advantage plans with myriad benefits, how do you choose the right one for you? Below is a checklist of items you want to consider when trying to make a decision if you are new to Medicare or just considering making a plan change.

1.  Do you want a PPO or HMO plan?  While most Medicare Advantage Plans are HMO’s, there has been an increase in the number of PPO’s being offered.  HMO’s require you to go to network providers or you won’t be covered.  PPO’s give you the option to go out of network, but you will pay more (in copays or coinsurance) if you do.  PPO’s normally have a higher premium because they give you this choice, but it might be worth it if you want to have the benefit of seeing out-of-network doctors.  Medicare Advantage Plan PPO’s should not be confused with Medicare Supplemental plans.  Supplemental plans have no networks but do require you to go to doctors who take Medicare.

2.  If you have a doctor or specialist you want to see, make sure they are in network for the plan you are considering.  Don’t assume that every doctor in a practice is contracted with the plan.  You can call the plan directly or look up the doctor online on the plan’s website to verify if they are in network.  Remember, however, that a doctor may discontinue his contract with the plan at any time, which means you would have to find a new physician if this were to happen.

3.  Do you have specific health issues you want addressed?  Some plans are designated as CSNP’s or Chronic Special Needs Plans.  These plans structure benefits to address certain illnesses like diabetes, certain heart conditions or end-stage renal disease.

4.  Are you on MediCal as well as Medicare?  There are DSNP’s or Dual-eligible Special Needs Plans that coordinate benefits with Medicare and MediCal to make it easier to access doctors and benefits.  They may include extra benefits like vision, hearing, dental, transportation and telehealth services. 

5.  If you take certain medications, make sure they are in the formulary of the plan.  Each plan has a unique formulary, or list of medications that they cover.  Be sure and check this list to ascertain your meds will be covered.  Some plans are part of the Senior Savings Model in which they cap the price of insulin at around $35. While you and your doctor can appeal to the plan to cover a medication that is not in the formulary, there is no guarantee that they will cover it.

6.  If you are new to Medicare, you may choose an Advantage Plan and find that this type of plan is not right for you.  If you cancel the plan within the first twelve months (from the effective date), you will have guaranteed issue rights to switch to a Supplemental plan, which means you can get a Supplemental plan without going through underwriting or answering medical questions.  If you wait longer than the twelve-month period, you would be subject to underwriting and could be turned down for a Supplemental plan.

Medicare is a complicated topic, so if you are confused, an experienced broker can help answer your questions and address your concerns. A local broker will be familiar with the plans available in your area, the physician networks contracted with the plans, and can help narrow down your choices based on your specific needs.

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