There are few decisions you can make that are more important than your health insurance.
Before you sign on the dotted line, you should understand how your insurance policy works. These questions will help.
When it comes to Medicare plans, you have options — maybe even too many. With Medicare Advantage, for instance, no two plans look exactly alike. They vary by location, carrier, and a host of other details. That can make it difficult to reach an informed decision.
Working with an insurance agent can help you sort through all the information. At ClearMatch Medicare, we’re committed to making sure you understand your options so you can decide what works best for you. We don’t want you to find just any plan; we want you to find the right plan. But that’s easier if you come in with a little background information and a few smart questions.
The questions here will help you explore whichever insurance policy you’re considering. By thinking them through now, you’ll start to get a better sense of your needs and wants regarding health insurance. So when you’re ready to talk, we are too. Just give us a call at 888-992-0738.
1. Are vision, hearing, and dental coverage included?
Original Medicare does not include vision, hearing, or routine dental care. If those are important to you, you’ll need to get them through a Medicare Advantage plan (or separate insurance plans).
But even then, you can’t take the services for granted. Some plans offer all three, while others may not provide any. If you’re not clear about the details of your policy, ask your agent.
2. Are my providers in-network?
If it’s important that you keep your current doctors, you’ll want to make sure they’re covered under the plan you’re considering, says Melinda Munden, director of the Seniors’ Health Insurance Information Program through the North Carolina Department of Insurance.
And this isn’t just a one-time check. Each year, you’ll want to look again to make sure your favorite doctors are still on the list. “Providers can choose to accept a plan one year and not the next,” Munden says. “And they may accept some plans from one insurance company but not others.” For example, they might take a PPO but not an HMO plan from the exact same insurance company.
If you need to change your plan, you can do it each year during fall’s Annual Enrollment Period (AEP) or during Medicare Advantage’s open enrollment (Jan. 1 to March 31).
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3. Will my current medications be covered?
Prescription drug plans offered through Medicare Advantage and Medicare Part D are not required to cover every medication at the pharmacy. But they are required to publish which drugs they cover.
So if you’re taking any medication, ask your agent whether it’s included in the plan. “A low premium can be a big draw, but if the policy doesn’t cover the prescriptions you’re taking, does that really benefit you?” Munden asks.
4. What will my monthly premium be?
The premium is the amount you pay every month to stay enrolled in your Medicare plan. Think of it as the cost of being insured: It’s the minimum amount you’ll pay, and you’ll be responsible for it even if you don’t go to any doctor’s appointments.
Original Medicare’s Part B (outpatient care) charges a premium, but many people are able to switch to a Medicare Advantage plan for no additional cost. (Although they do still have to pay the monthly Part B premium.)
5. What is the out-of-pocket limit?
In addition to your premium, your Medicare plan will include a deductible (the amount you pay before the plan kicks in) and co-insurance (the percentage you pay after you meet your deductible). Depending on the plan, you may also have co-pays, which are fixed amounts you pay for certain services.
As you might imagine, these numbers can add up. If you break a hip or have a heart attack, you could end up in medical debt. That’s where an out-of-pocket maximum comes in. This is the most you can possibly spend during any one calendar year. After that, your insurer picks up 100% of the bill.
Original Medicare does not have an out-of-pocket maximum. You could theoretically be billed tens or even hundreds of thousands of dollars. But Medicare Advantage plans do, and the average for in-network services is a little over $5,000, according to the Kaiser Family Foundation. Once you hit that number through your deductible, co-pays, and co-insurance (premiums don’t count toward your maximum), the plan will pay for everything.
6. Speaking of co-payments, what will I be responsible for?
A co-payment is a set fee you pay in exchange for a healthcare service. For example, maybe you have to pay $25 every time you visit your dermatologist or $15 when you pick up covered medication at the pharmacy.
Not every plan includes co-pays, but you should know for sure. That will help you better estimate what you might be paying for various types of care you expect to receive.
7. If I am not happy, can I get out of it?
It’s recommended that you ask your broker when you can switch plans if you’re ultimately not happy with the one you chose, says Crystal Strong, program manager of the South Carolina State Health Insurance Assistance and Senior Medicare Patrol programs. The Medicare Annual Enrollment Period runs from Oct. 15 through Dec. 7, but there’s an additional enrollment period for Medicare Advantage plans, which begins on Jan. 1. So there are two times to potentially make a change, depending on what type of plan you sign up for.
There are also “qualifying events” that may allow you to change your plan outside of those official enrollment periods — such as moving out of a covered service area, getting married, or being dropped by your insurer through no fault of your own. Your broker can point you toward qualifying events that would likely apply to you.
8. If I travel out of state, will I still be covered?
Original Medicare can be used in any U.S. state, but Medicare Advantage plans may limit you to a smaller local network. If you visit a doctor outside your approved area, you could end up paying more money than you planned on.
If you travel a lot or split your time between two states, this might make a big difference in the plan you choose.
9. What are my options for Medigap?
Medigap, or Medicare Supplement plans, pretty much covers all your healthcare costs - assuming Medicare covers the service. “Medicare pays 80% of costs they approve, and you are left with 20%. But if you buy a Medicare supplement, that may pick up that 20%,” says Strong. “So you’re generally left with nothing out of pocket other than your monthly premium.”
The downside: Medigap premiums can be pricier than those on the Medicare Advantage market, and they won’t cover prescriptions, dental, vision, or hearing.
Still, depending on your health status and what type of care, procedures, and treatments you may need, Medigap might make sense. In the long run, it could even save you stress and money. ClearMatch Medicare agents are experts in Medicare, so they can help you determine if Medigap is right for you.
You can also research your Medicare plan options with our Find a Plan tool. Just enter your zip code to review Medicare plans in your area.