Section 3: Costs and Coverage
5 Questions to Consider When Choosing Coverage
You’ll need to take your budget and lifestyle into account
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• Can you keep your doctors?
• Will your prescriptions be covered?
• Do you have preexisting conditions?
• Are plans available in your area?
• Do you travel frequently?
Choosing how you will receive your Medicare benefits is a personal decision. They need to fit into your lifestyle, health status and budget. Whether you’re leaning toward original Medicare, also known as traditional Medicare, or a private Medicare Advantage plan, consider the following questions.
1. Can you keep your doctors?
If you want to continue seeing your well-loved doctors, ask if they accept original Medicare and which, if any, Medicare Advantage plans they participate in.
If your doctors aren’t in a Medicare Advantage plan’s network, ask how much you would have to pay to continue seeing them. Some plans don’t cover out-of-network providers except in emergencies. Others charge higher copayments or coinsurance — your share of the costs — if you don’t use doctors in the plan’s network. Some Medicare Advantage plans also require a referral from a primary care doctor to see a specialist.
2. Do you have preexisting conditions?
One of the great things about Medicare is that it covers your existing health problems, regardless of whether you choose original Medicare or Medicare Advantage. But that’s not always the case with Medicare supplement insurance, also known as Medigap.
These private plans help you pay for out-of-pocket costs, such as the Part A deductible for a hospital stay. In 2023, the deductible is $1,600 per benefit period, and you could face more than one benefit period in a year. Medigap also helps cover Part B's 20 percent coinsurance for doctor and outpatient services.
If you decide to enroll in original Medicare and purchase a Medigap policy, you can buy any policy in your area, regardless of any preexisting medical conditions, within six months of enrolling in Part B, which covers doctor visits and outpatient services. But after those six months, if you have a health issue and want to buy or switch Medigap policies, an insurance company may be able to deny or delay coverage or charge you a higher premium.
A few states — including California, Connecticut, Maine, Massachusetts, Missouri, New York and Oregon — do allow you to switch Medigap policies regardless of your health. But when this is allowed and the plans you can switch into vary among states, so check with your state insurance department.
If you have a Medicare Advantage plan and a preexisting medical condition, you may have trouble getting a Medigap policy if you decide to switch back to original Medicare. However, in some circumstances, you can purchase a Medigap plan despite a preexisting condition after those first six months.
Change of heart. If you leave original Medicare, buy a Medicare Advantage plan for the first time and switch back to original Medicare in less than a year
Second thoughts. If you select a Medicare Advantage plan when you first enroll in Medicare but decide within the first year that you want to switch to original Medicare
Change of venue. If you move out of your Medicare Advantage plan’s service area, you have rights, in limited situations, to buy a Medigap policy without worrying about preexisting conditions.
3. Will your prescriptions be covered?
Whether you’re considering a stand-alone Part D prescription drug plan or drug coverage through a Medicare Advantage plan, you’ll need to find out how much you would have to pay for your prescriptions.
Even if your medications are included in a plan’s formulary (the list of covered drugs), plans can charge different copayments or coinsurance amounts for the same medications. You may pay less if you use preferred pharmacies, so make sure that they’re convenient for you. You also should find out whether your drugs are subject to additional regulation within a plan, such as prior authorization from your insurer before you can buy them or limits on the number of doses covered within a certain time.
4. Are plans available in your area?
Where you live can affect your access to doctors, hospitals and even the type of coverage available to you. With original Medicare, you have access to participating doctors and hospitals across the United States.
Medicare Advantage plans use networks of providers, and the covered doctors and hospitals usually are limited to certain geographic areas. If you live in a rural area, you may have fewer provider options or you may have to travel farther to find doctors and hospitals in the plan’s network. Find out which hospitals are in a plan’s network.
5. Do you travel frequently?
You may want to spend more time in another state, either in a second home or visiting children and grandchildren. If you live in two states, you may not be able to enroll in a Medicare Advantage plan that will cover you in both of your homes.
In addition, the plan might not cover out-of-network providers except in emergencies. Or it may charge more to go to doctors outside your plan’s network.
Medicare is also tricky when you travel abroad. You can’t expect coverage — even in an emergency — although some Medicare Advantage plans cover emergency care abroad. In some limited circumstances, original Medicare will pay for care in a foreign hospital or aboard a cruise ship.
If you have original Medicare, you can buy a Medigap plan that offers some foreign travel benefits. Some plans cover 80 percent of the charges for emergency care outside the United States, with a lifetime limit of $50,000.
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