Questions to Ask When Comparing Medicare Plans 

• Is the plan in my service area?
  
  Original Medicare can be used with any provider in the U.S. who accepts Medicare as payment. 

Medicare Advantage plans work in specific service areas. You are required to live in the plan service area to enroll. Each plan will include a description of its service area in the plan materials.
 

• Are my doctors in-network?
  
  Make sure any health care providers you would like to continue seeing will be covered by your Medicare plan. 

If you are on Original Medicare, you can see any health care provider that accepts Medicare as payment. 

If you will be enrolling in a Medicare Advantage plan, check the plan’s provider directory to verify that your providers are participating with that plan. Primary care physicians and specialists are included in the provider directory. 
 

• Are my prescriptions covered?
  
  Make sure your prescriptions will be covered by your Medicare plan. 
   

Original Medicare does not cover prescription drugs. If you need coverage, sign up for a Medicare Advantage plan that includes prescription drug coverage. Or, sign up for a Medicare Part D plan. 

Medicare Advantage plans and Medicare Part D plans publish a list of all of the drugs they cover called a formulary. This list is updated every year to make sure it includes the most effective drugs available. Your medications need to be on the formulary to be covered by your insurance. 

If your medication is not on the formulary, your provider may be able to help you find a similar drug that will work just as well. 

Medicare Advantage and Part D plans will also have a list of pharmacies that are in their network. Check to make sure that their in-network pharmacies are convenient for you. 
 

• What is the difference between HMO, PPO and D-SNP plans offered by Medicare Advantage?
  There are a few different ways that health insurance companies work with providers to deliver health care services. 

Health Maintenance Organization (HMO)
HMOs create a network of doctors, hospitals and other health care providers who agree to certain payment rates for the services they provide. This allows the HMO to keep costs under control for its members.

Pros and Cons
 

• HMOs usually have lower monthly premiums, copays and coinsurance than other types of insurance.
   

• HMOs do not cover any care from out-of-network providers, unless it is an emergency.
   

• Your care will be coordinated by your primary care physician (PCP). You will need to get a referral from your PCP if you need to see a specialist.
   

Preferred Provider Organization (PPO)

Like an HMO, PPOs create a network of doctors, hospitals and other health care providers who agree to certain payment rates for the services they provide. The difference is that PPOs are more flexible in which providers you can see for your care compared to HMOs. 
 

Pros and Cons
 

• PPOs allow you to see any provider, in or out of network, for your care.
   

• You are not required to choose a PCP or get referrals from a PCP to see a specialist.
   

• PPOs typically have higher monthly premiums, copays and coinsurance than other types of insurance.
   

Dual Eligible Special Needs Plan (D-SNP)

D-SNP is a type of Medicare Advantage plan that offers health care coverage for people who are eligible for both Medicare and Medicaid (dually eligible individuals). 
 

• How much does it cost?
  There are a few main costs that contribute to the total cost of your Medicare coverage. Be sure you understand how much you will pay for each of these parts as you compare plans. Each plan publishes the costs for the current plan year for each of these parts.
   

• Premium
   

• Deductible
   

• Copay or coinsurance
   

• Out-of-pocket costs
   

• Extra benefits
   

• What else should I consider when comparing Medicare plans?
  
  There are additional questions you can ask to help find a plan that is a good fit for you.

Is the plan local or national?

Local plans may have a better understanding of your community. The call center representatives are more likely to be based in your area rather than across the country or around the world. 

National plans may offer a broader network of providers across the country. 
 

How does the plan handle my medical records?

Medical records access can make it easier for your providers to work together to provide your care. It can also make it easier for you to quickly get information about your health, like test results. 

Find out how the plan handles your medical records and how they provide you with access to the information.
 

Is the plan nonprofit or for-profit?

Nonprofit plans can focus on the communities they serve rather than generating profits. 
 

How often does the plan make changes to its provider network?

The stability of the plan’s provider network can make a difference in your health care experience. If you find a provider you like, you want to be able to continue to see them. You also want to have a robust provider network to choose from, so check to see the number of providers participating with the plan and ask how new providers are added to the network. 
 

Does the plan help to work closely with your providers?

Some plans are working to make it easier for all of your providers to work together. They are also working to make it easier for you to get many of the health care services you need all in one location. This is sometimes called integrating care.
 

Look to see if the plan has ambulatory centers in network that provide a range of outpatient services all under one roof.

What is the plan’s star rating and why is it important?

Medicare gives star ratings to Medicare Advantage plans based on their performance. The star ratings are updated on a yearly basis. A plan can get a rating between one and five stars. A 5-star rating is the highest rating. 

You can look up a plan’s star rating in the Medicare and You handbook, on the Medicare.gov website, and on the plan’s website.
 

A plan has to be operating for three years before they can be awarded a star rating. Consider both the star rating and the other components to pick the best plan for you.
 

Are there any aspects of your lifestyle that you need to consider when selecting a plan?

Do you travel out of the country? Are you a snowbird? An important part of picking a Medicare plan is finding a plan that will be there for you in the next phase of your life. Check to see how the benefits will support you in the coming phases of your life.