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Top 10 Questions to Ask Before Enrolling in a Medicare Advantage Plan

There are a lot of Medicare Advantage (MA) plan options out on the market now across Iowa, and you are likely seeing and hearing about all of them through TV and radio ads, mailed materials, and calls. Medicare Advantage plans can be a great option for some individuals, but choosing to enroll in an MA plan is an important decision that requires careful consideration. This article helps you think through whether or not an MA plan would be a good fit considering your health, finances, and lifestyle.

Below are the top 10 questions to answer before you decide to enroll:

  1. What providers or facilities do you use?

Medicare Advantage plans contract with a network of hospitals, doctors, and other providers. It is critical that you check to see if your doctors, hospitals, or other specialized providers accept the plan before you enroll. If they do not accept the plan you may need to change providers in order to receive coverage through the MA plan.

  • If you enroll in a Health Maintenance Organization (HMO) plan and receive care from a provider that is out-of-network without a referral, then neither the MA plan or Medicare will pay. This means you will be responsible for the entire bill.
  • If you enroll in a Preferred Provider Organization (PPO) plan you can go to a provider that is out-of-network and receive coverage, as long as the out-of-network provider accepts the PPO Plan. If the out-of-network provider does not accept the plan, you could be responsible for the entire bill. If the provider does accept the PPO plan but is out-of-network, in many cases the copay and coinsurance will cost more than in you go to an in-network PPO provider. 
  1. What medications do you take?

Most Medicare Advantage plans include prescription drug coverage. Just like a Part D plan, an MA plan’s prescription drug coverage and formulary can change from year-to-year. Out-of-pocket costs will depend on how your specific drugs are covered, and what copayments or coinsurance are required for each prescription. Be sure to check requirements for:

  • Prior-Authorizations: Will the plan require you to get prior authorization from your prescribing provider before approving a drug? Some plans may require you to try a lower-cost alternative before a certain drug will be approved.
  • Quantity Limits:The plan may limit the dosage allowed over a specified period, e.g., x milligrams over a 30-day period. Such dosage restrictions can create issues for chronically ill individuals who take high dosages of prescription medications on a maintenance schedule.
  • Step Therapy:Some plans may require you to try a lower-cost alternative before a certain drug will be approved. Plans may require a trial of up to 90 days on a different medication, which may be completely unacceptable for some patients

    We recommend visiting with a SHIIP/SMP counselor between October 15th and December 7th every year to review your coverage and compare costs between plan options.
  1. Do you want your care choices to be managed by your insurance?

Medicare Advantage plans manage both your Part A and Part B coverage, which means in many cases your provider will be required to gain prior authorization from your MA plan before moving forward with a procedure.

  1. Do you travel outside of your county or state? How often and how long?

Since Medicare Advantage plans are contracted with a network of providers, coverage may or may not extend to providers in other parts of the state or country. Do you spend part of the year in another state? If you do, make sure that the Medicare Advantage option will provide you with access to the care you need. Coverage may not be provided with out-of-state providers unless you receive emergency or urgent care. Alternatively, Original Medicare allows you to receive care from any Medicare provider anywhere in the United States.

  1. What are your out-of-pocket costs with the Medicare Advantage plan?

You must still be enrolled in Medicare Part A and Part B to have MA plan coverage, and you are still required to pay the Part B monthly premium. All Medicare Advantage plans sold in Iowa have an annual contract with Medicare. MA plans set premiums, coinsurance and copayment annually – so costs and coverage can change from year to year. This includes contracts with providers. Check if your providers and pharmacy are in-network for the plan. All Medicare Advantage Plans must set an annual limit on your out-of-pocket costs, known as the maximum out-of-pocket (MOOP).  PPO's have both an in-network MOOP and out-of-network MOOP.   

  1. Are any of the extra benefits provided by the Medicare Advantage plan important to you (e.g. dental, vision, hearing, health club membership, etc.)?

Most Medicare supplements do not include coverage for dental, vision, hearing, or health club memberships. If these extra benefits are important to you, check to see if the Medicare Advantage plans available in your county offer these options. Be sure to verify which providers you can access for dental, vision, hearing, health club membership.

If you want to continue with Original Medicare and a supplement you could look into purchasing a separate dental or vision policy. Contact SHIIP for a list of companies.

 

  1. Do you know your options if you want to switch back to Original Medicare?

If you are enrolling in a Medicare Advantage plan for the first time you can return to Original Medicare and are guaranteed to be accepted in a Medicare Supplement plan without underwriting in two situations:

  • You dropped your Medicare supplement to enroll in a MA plan for the first time, but disenroll from the MA plan within the first 12 months.
  • You enroll in a Medicare Advantage plan for the first time during your initial enrollment period (when you turn 65), but you disenroll from the MA plan within the first 12 months.

In either of those circumstances, you will have the option to either re-enroll in the plan you were most recently in, or (if that policy is not available) you can enroll in certain Medicare Supplements from any company selling those plans in Iowa without going through the underwriting. In both of those circumstances, you would also get a special enrollment period to sign up for a Part D plan.

8. Do you qualify for payment assistance?

If you have full Medicaid benefits or if you are enrolled in the QMB Medicare Savings Program, your providers cannot bill you for the cost of deductibles and copayments for Medicare Part A and Part B covered services in Iowa. This is true if you are enrolled in Original Medicare or a Medicare Advantage plan. You can be billed for services received from providers who are out-of-network for your Medicare Advantage plan Depending on the plan, you may be responsible for the entire bill.

If you think you may qualify for payment assistance, but are not currently receiving those benefits, you can check your eligibility here: https://shiip.iowa.gov/eligibility-survey

A SHIIP/SMP Counselor can help you apply for assistance and can help you compare the costs and benefits of any Medicare Advantage plans.

     9. What Medicare Advantage plans are available in my county?

SHIIP/SMP publishes a Guide to Medicare Advantage plans in Iowa. The 2023 Medicare Advantage Guide will be available soon on our website. This resource provides more detailed information about specific Medicare Advantage plans – including information about service areas, premiums, cost share for some Part A and Part B services, and additional benefits. The new MA guide will be available soon. 

While the Medicare Advantage Guide is a helpful tool, we still recommend contacting your providers directly and seeking support from a SHIIP/SMP counselor before making any decisions about enrollment.

10. Where can I find a SHIIP/ SMP Counselor to review my options?

      Find a SHIIP/SMP Counselor near you by calling us at: 1-800-351-4664.

       Or, you can identify local SHIIP/SMP Sponsor Site locations on our website at: https://shiip.iowa.gov/find-a-shiip-counselor