New to Medicare Advantage? Here’s Your Startup Checklist
Updated: Apr 17
One aspect can determine your experience with a Part C Medicare Advantage program: how smoothly you can transition to using the new insurance.
Once you have enrolled in a Medicare Advantage plan, the following checklist of actions will increase your chances of having a good experience.
Get your insurance company’s Medicare Advantage card and directories
The new-member packet you receive by mail should include your Medicare Advantage member ID card, plus printed or access to digital versions of your Evidence of Coverage (EOC) and Summary of Benefits. Those documents become your guides to using your plan. You may also have a listing of covered medications (formulary) for your prescription drug coverage. Note how to contact your plan provider if you have customer service issues or questions. And always bring your plan’s card – and not your red-white-and-blue Medicare card – with you to your doctor or pharmacy.
Understand your plan’s payment structure
Medicare Advantage plans have different annual deductibles, copayments and yearly out-of-pocket maximums. Read your Evidence of Coverage and Summary of Benefits documents to understand exactly how these work so you can keep your medical expenses to a minimum.
Understand how your plan’s network works
Medicare Advantage plans come in various types, such as HMOs, PPOs and HMO-POS. Identify what type you have, and confirm your exact coverage and costs before making any appointments for visits or services.
With an HMO, you must stay within your plan’s defined network if you want your care to be covered, unless it’s an emergency. Your plan has contracted with various doctors, specialists, hospitals and other facilities who agree to offer services at a negotiated rate. By staying in the network, you know the copayment you will be required to pay, but if you go outside the network, you may have to pay the bill in full.
With a PPO, you have more flexibility in the doctors you can visit. If you see an in-network doctor, you will likely have a fixed copayment, such as $25 per visit, determined by your plan. If you go to an out-of-network provider, you will still have coverage, but your part of the bill will be larger.
With an HMO-POS, you are somewhere between an HMO and PPO: most plans require you to use in-network providers for medical care but let you go outside the network for specific services.
Find a Primary Care Provider
Hopefully, when you researched Medicare Advantage plans before enrolling, you found a plan that includes some – or at least the most important – doctors you currently work with. If you don’t have a Primary Care Provider (PCP) who is in the network, that should be your priority because access to specialists and certain services may require referrals from your PCP.
When you make appointments with in-network doctors, you must provide your new insurance information and follow the plan’s requirements regarding PCP referrals.
How to choose new doctors
You may start your search for doctors by asking friends and family members for referrals, or you may do internet searches. You may combine your online searches with the information in your plan’s provider directory, which may have come in your new-member packet or found online. Remember that different hospitals are also in-network or out-of-network, and doctors are affiliated with specific hospitals. Your questions should include the following:
Does the doctor accept my Medicare Advantage plan?
What hospitals is the doctor affiliated with?
Is the doctor available off-hours for emergencies?
Schedule your “Welcome to Medicare” visit
When you enroll in Medicare, you have 12 months from the date you first enroll in Medicare Part B to complete a one-time-only preventive doctor visit paid fully by Medicare Part B. The information gathered during this visit by your PCP becomes the foundation of your Medicare records, so you may want to bring your medical records, immunization history, detailed family history and list of medications and their dosages. Your PCP will review your medical/surgical history, medications, mental outlook, family health history, alcohol and tobacco use, and diet and exercise. Diagnostic tests and other services not part of the formal Welcome to Medicare visit will trigger copayments for you, so be sure your doctor stays within its guidelines unless you’re prepared to pay.
Understand your choices for immediate medical care
Large and small emergencies don’t necessarily happen during regular business hours. So you’ll want to understand your best options if your doctor can’t see you.
If you feel your life is at risk, call 911. In the case of emergencies, your plan will usually cover you whether you use services inside or outside your network.
However, when it’s not an emergency, such as minor cuts or colds, a walk-in clinic or urgent care center may be faster and less expensive than an emergency room. But if you’re facing severe injuries or life-threatening illness, your best destination is an emergency room.
With your new policy, go through your plan literature and identify the walk-in clinics, urgent care centers and emergency rooms closest to you and in your network. That way, if you ever need them, you have addresses, hours, and phone numbers at your fingertips.
Check your plan’s prescription drug plan
Most Medicare Advantage plans include a prescription drug plan which, hopefully, you researched to find one that covers all or most of your existing prescriptions. You should have access to lists of covered drugs (formularies) that include what tier (or price group) the drug is in and lists of network pharmacies. Check if your plan has preferred pharmacies where prices may be lower.
Sometimes pharmacies price medications differently, so you may want to check more than one. Check your pharmacy options, then select the pharmacy with the best prices that is the most convenient to you in terms of distance and hours. If you have prescriptions at another pharmacy, transfer them to your new pharmacy.
Don’t overlook the option of prescription mail-order services if your plan offers them.
Investigate your plan’s extra benefits
Insurers offer additional benefits that help you with the cost of care that targets your total health and wellness. These benefits typically include dental, vision and hearing care. Plans can also include fitness programs, transportation, over-the-counter health items, meal programs and others. To make the most of your plan, read the information in your new-member packet or online for how to access those benefits.
Make a note of your plan’s available help
Your plan will have a member services phone number you can call for help with questions and concerns. Store the number in a convenient location – next to your phone or in your cell phone – noting what days and hours help is available. As you start a plan, you will likely have more questions, and it’s better to get answers first rather than make potentially costly mistakes.
Also, note if your plan offers a 24-hour nurse line and keep that contact phone number handy.