Understanding your health care needs can help you make the right Medicare choice for you.
It's important to understand your personal needs so that you can customize your Medicare coverage choices to meet them.
These questions are a good place to start. Read through them and make notes as you think of things. You may want to start a file to keep Medicare information and documents that you gather during your decision-making process.
Medicare Needs Assessment
The answers to these questions can help you choose Medicare coverage that may fit with your needs.
Questions to Ask Yourself
Why You Need to Know
How often do you visit the doctor, in general?
Frequent doctor visits can get costly.
With Original Medicare, you pay 20% of the Medicare-approved amount for most doctor services after you meet the Part B deductible.
With most Medicare Advantage plans, you pay a set copayment for each visit after you meet the Part B deductible (if any).
With either type of coverage, you also pay a monthly Part B premium to Medicare.
The amount Medicare determines to be reasonable for a covered service. Providers who “accept assignment” agree to accept this amount as payment in full. Providers who accept Medicare but not assignment can charge up to 15% above this amount.
Do you have a particular doctor, hospital or pharmacy that you want to use?
Many Medicare Advantage plans contract with a network of providers and pharmacies to get special pricing. Plan members generally pay less out-of-pocket for care and services they receive from network providers. If your preferred provider or pharmacy is not in the network, you may pay more for the same care and services. With Original Medicare, you can use any provider in the country who accepts Medicare.
Do you have a chronic condition such as diabetes or congestive heart failure?
Chronic conditions may require regular health care with frequent visits to doctors or specialists. Look for coverage choices that address the care you may need at a cost you can live with. Sometimes a Medicare Advantage Special Needs Plan can be a good fit in this kind of situation.
Do you have the last stage of kidney failure (End Stage Renal Disease (ESRD)?
End Stage Renal Disease (ESRD)
Permanent kidney failure requiring dialysis or a kidney transplant.
People with ESRD generally can’t enroll in a Medicare Advantage plan and must stay with Original Medicare. Exceptions apply.
How is your health, in general? Has it changed recently, such as receiving a new diagnosis? Do you have any planned surgeries or procedures coming up?
A change in your health status could mean that you will require more care and services in the future. Understanding the care and services you may need will help you compare Medicare coverage choices. Your doctor may be able to help you with this.
What prescription medications do you regularly take?
Most prescription drug plans and Medicare Advantage plans that include drug coverage have a formulary. If your drugs are not on your plan's formulary, you may have to pay more. Look for a plan that covers the drugs you take. Sometimes a plan will cover a similar medication that you can substitute.
A list of the prescription drugs that are covered by a specific Medicare Part D plan.
Do you have other health coverage, such as through your or your spouse’s current employer?
Many people who have employer or union health insurance enroll in Medicare Part A and refuse Part B. Part A is premium free for most people and will cover hospital expenses as secondary insurance. Part B charges a premium, which you can avoid paying until you need the coverage—without penalty as long as you qualify for a Special Election Period. Also, you can delay getting prescription drug coverage without penalty if you have creditable coverage through another source.
Prescription drug coverage from a health plan other than a Medicare Part D standalone plan or a Medicare Advantage plan that includes prescription drug coverage and that meets certain Medicare standards.
Do you have retiree health coverage, such as through a union, the military or a former employer?
It’s important to talk to your plan administrator about how your plan may work with Medicare before you make any decisions. You may have more options than the usual ones.
Do you travel frequently or live part of the year in a different state?
Many Medicare Advantage plans contract with a network of providers and pharmacies within a geographic service area. Plan members generally pay less out-of-pocket for care and services they receive from network providers. You may pay more if you need services while travelling. Original Medicare provides coverage nationwide.
In Medicare Advantage, the area in which a plan offers service. A service area is typically a county, state or region.
Do you live in a long-term care residence or skilled nursing facility (nursing home)?
Medicare limits the number of days it will cover for care in a nursing home. You’ll need to figure out whether your care will be covered under different plan choices, for how long and at what price.
What did you pay out-of-pocket for health care over the past 12 months? What did you pay for your prescription drugs?
It’s important to understand your out-of-pocket health care costs so you can compare what you’re paying now with what you might pay with a different plan.
Does your doctor accept Medicare assignment?
Some doctors do not accept assignment and may charge more than Medicare allows for some services. The additional cost is referred to as excess charges. Doctors who do not accept Medicare assignment may bill you for excess charges.
Additional Launch Content. Term used to indicate a doctor's agreement to take the Medicare-approved amount paid for a service as full payment. If your doctor accepts assignment, your share is limited to your co-insurance payment, usually 20% of the Medicare-approved amount.