Don't Just Pick a Medicare Plan
"I just need to pick something." I hear some version of this all the time. And I completely understand it.
Medicare can feel overwhelming. There are plan names, premiums, networks, drug lists, copays, deductibles, specialists, pharmacies, extra benefits... and enough Medicare terminology to make your head spin. So sometimes the easiest thing to do feels like finding a plan that looks good, checking the box, and moving on. But when it comes to Medicare, "just picking something" can mean missing something important.
The $0 premium trap
One of the first things people often notice when looking at Medicare Advantage plans is the premium. And when you see $0 premium, it's certainly worth paying attention to. But $0 premium does not mean $0 cost.
Medicare Advantage plans can have $0 monthly premiums, but you still have your Part B premium, and plans can have different deductibles, copayments, coinsurance, and out-of-pocket limits.
So I don't think the question should simply be: "Which plan costs me the least every month?"
A better question is: "Which plan makes the most sense for me and the way I use my healthcare?"
Those are two very different questions.
Medicare isn't one-size-fits-all
The plan that works beautifully for your neighbor might not be the right fit for you. Maybe your neighbor rarely goes to the doctor, takes two generic medications, and doesn't have any specialists. You might see three doctors, take six prescriptions, have a specialist you absolutely want to keep seeing, and use a particular pharmacy. Those two people have very different healthcare needs. That's why choosing a Medicare plan should start with you, not with the plan's premium.
What should you look at?
Before choosing a plan, I think it's important to look at the whole picture.
Your doctors
First things first: are your doctors in the plan's network?
If you have a primary care doctor you really like, check them. But don't stop there. If you see a cardiologist, oncologist, endocrinologist, orthopedic specialist, dermatologist, or any other specialist, check those doctors too. A plan can look fantastic on paper, but if the doctors you rely on aren't participating, that could be a very important piece of the puzzle. Medicare Advantage plans generally use provider networks, and going out of network can mean paying more depending on the plan.
Your prescriptions
Next up: your medications.
Don't simply check whether the plan has prescription coverage. Check your actual medications. Look at whether your prescriptions are covered, what tier they're on, what you'll pay, and whether your preferred pharmacy is in the plan's network. Medicare drug plans have formularies, and the drugs covered and their costs can vary by plan. A plan that looks great until you add your prescriptions into the equation may suddenly look very different.
What can I do if my prescription isn't on my Medicare Part D plan's list of covered drugs?
First, check to see if your plan covers a similar medication. Medicare Part D plans have their own formularies (lists of covered drugs), and sometimes your doctor can prescribe an alternative that works just as well. But if your doctor believes the covered alternatives won't work for you or could cause harmful side effects, you may be able to ask your plan for a formulary exception. Your doctor will need to provide information supporting why you need that specific medication.Your specialists
If you see specialists regularly, this deserves extra attention. Some Medicare Advantage plans may require referrals for specialists, and plans can have different rules for services and prior authorization.
Ask:
- Are my specialists in-network?
- Will I need referrals?
- Are there prior authorization requirements for services I regularly receive?
- What will my copays or coinsurance be?
Your hospital and other providers
Don't forget about hospitals, labs, imaging centers, physical therapy, home health, and other providers you may use. Your healthcare isn't just your primary care doctor.
Think about the entire healthcare picture.
Your costs
This is where that $0 premium comes back into the conversation. Look beyond the monthly premium.
Consider:
- Deductibles
- Primary care copays
- Specialist copays
- Hospital costs
- Outpatient services
- Prescription costs
- Coinsurance
- The plan's maximum out-of-pocket limit
Medicare Advantage plans have an annual out-of-pocket limit for covered Medicare services, but that limit varies by plan. Sometimes paying a little more in premium can make sense for someone's overall healthcare needs. And sometimes a $0 premium plan really can be a great fit. The point is that premium should be one part of the decision, not the entire decision.
What about the extra benefits?
Dental. Vision. Hearing. Transportation. Over-the-counter benefits. Fitness programs. These benefits can be valuable, and they are certainly worth looking at. But I would encourage you not to let one attractive extra benefit make the entire decision. A plan might have a fantastic dental benefit, for example, but if your doctors aren't in-network or your prescriptions are expensive, you have to look at the whole picture. One great benefit doesn't necessarily make a great overall fit.
Think of it like buying a car
Here's an easy way to think about it.
Imagine you're shopping for a car. One car has the lowest monthly payment you've ever seen. Sounds great! But then you discover it doesn't have enough room for your family, it doesn't have the features you need, and the gas mileage isn't very good. Was it really the best deal? Maybe. Maybe not. You have to look at what you're getting for what you're paying. Medicare is similar.
Look at the whole picture.
The goal isn't the "best plan"
There isn't one Medicare plan that's the best for everyone. The goal is to find a plan that is a good fit for you.
Your doctors. Your specialists. Your prescriptions. Your pharmacy. Your healthcare needs. Your budget. Your preferred benefits. Your comfort level with the plan's rules.
All of those pieces matter.
That's why I always encourage people to slow down before checking that box. You don't need to become a Medicare expert. You just need to make sure the plan you're choosing actually fits the person who is going to use it. And if you're not sure what to look for, that's where a Medicare agent can help.
What are the reasons why I should work with a Medicare agent?
It is important to work with an agent to guarantee that you are receiving all the benefits you are entitled to. I can also walk you through all the important topics and help you choose the best plan for you.We can walk through your doctors, prescriptions, specialists, pharmacies, costs, and the benefits that matter to you, and help you understand how the different options compare. Because Medicare isn't about finding the plan with the prettiest brochure or the lowest number on the screen.
It's about finding coverage that makes sense for you.
And that's worth taking a little extra time to get right.