Let’s assume you have chosen to meet your health care needs with a Part C Medicare Advantage plan, and your latest plan has covered you for at least this past year.
You can change plans a few times during the year if you are unhappy with what you have. Those times include:
Medicare Open Enrollment Period (October 15 - December 7)
Medicare Advantage Open Enrollment Period (January 1 – March 31)
Special Enrollment Periods (any time you are eligible for reasons such as moving, qualifying for Medicaid or losing other coverage)
5-Star Special Enrollment Period (between December 8 of this year and November 30 of next year)
But how do you decide if you’re happy with your existing plan or if you’d like to change plans when the occasion presents itself?
Answering a series of questions can help.
Ten Happiness Questions
The first step to answering some questions about your medical coverage would be to think back through your health care experiences with your Medicare Advantage plan over the past year.
If you have no experience with a particular question, you could refer to the written Summary of Benefits you received with your plan that described your insurer’s commitment to you.
Here are the ten questions:
Referrals: With most Medicare Advantage plans, you need to get referrals from a primary care doctor to see a specialist or access a hospital if you want the cost covered. Is your plan reasonable in its referral system?
Access to doctors: Finding a doctor who accepts your plan can be difficult with some plans. (PPO plans are more flexible than HMOs in what doctors you can see, but premiums could be higher.) Are enough of your preferred doctors and hospitals included in your plan’s network? And, if not, does your plan allow you to see doctors outside its network if you accept to pick up a portion of the cost?
Prescription drug coverage: Most Medicare Advantage plans bundle prescription drug coverage into the policy and list the medications they cover on formularies organized by “tier.” (The higher the tier, the higher the cost.) Does your plan cover enough of the medications you take now, and does it cover enough of the cost for those drugs?
Out-of-pocket limits: The out-of-pocket limit is what you must spend before your plan pays 100% for the rest of the year. By law, a plan’s out-of-pocket spending limit can’t exceed $7,750 in 2022, but it can be less. (For in-network services, the average cap in 2022 was $4,972.) So, if you were to have a year with extensive health care issues, would you be able to afford to cover your plan’s maximum out-of-pocket amount?
Out-of-pocket spending: Your out-of-pocket expenditures are deductibles, copays and coinsurance amounts for doctor visits, hospital stays, lab work services and ambulances, for example. Your plan has a published schedule of shared costs for each event. Can you afford those payments?
Monthly premiums: Nearly 70% of Medicare Advantage plans have a monthly premium of $0. (These plan premiums are almost always in addition to your Medicare Part B monthly premium.) But if you pay a slightly higher plan premium, your other costs (like deductibles, copays and coinsurances) could go down. So are you paying your ideal monthly premium?
Extra benefits: Most Medicare Advantage plans offer extra coverage (such as hearing, vision and dental care) in addition to Part A (hospital insurance), Part B (medical insurance) and prescription drug coverage. Does your plan offer extra benefits that are important to you – and when you use each benefit, does it cover what you understood it would?
Travel coverage: Most plans don’t cover you when you travel overseas – or even if you travel outside your local coverage area. (Some do cover emergency care.) So if you travel domestically or internationally, will your plan cover some of the expenses you incur – and, if so, does it cover enough?
Fitness services: Does your plan offer fitness services (such as the SilverSneakers program) that are convenient and useful to you?
Company likeability: You learn the most about a company when things don’t go exactly right. Are you comfortable with your plan’s insurer regarding professionalism, customer service and communication?
So is it time to change your Medicare Advantage plan?
Make a list of the elements to which you answered “yes.” And if you answered “no” to any of the ten questions, make a list of elements you want to improve when you select your next plan. That becomes your wish list.
But even if you answered “yes” to everything, you may not want to keep the same plan for two reasons:
Your health needs, financial situation and personal circumstances may have changed since last year.
Your plan’s costs, coverage and benefits may be changed for the upcoming year. (Your insurer has the right to change a plan’s elements each enrollment period, as long as they announce changes in the Annual Notice of Change, or ANOC, letter they must send you before the open enrollment period.)
Takeaway action step: With your wish list in hand, access Medicare’s comprehensive Plan Finder to look for plans in your geographic area that fulfill as many of your wish list items as possible. With so many Medicare Advantage plans available in most locations, you should be able to come close to the ideal plan for you.