Understanding Your Health Care Needs

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Understanding your health care needs can help you make the right Medicare choice for you.

Your lifestyle, medical history and plans for the future—even the doctors you see—are all things to think about before making a decision about Medicare. It’s important to understand your personal needs so that you can customize your coverage choices to meet them.

The questions in the needs assessment on this page are a good place to start. As you read through them, you may think of others. It’s a good idea to make notes as you think of things. You may want to start a Medicare file to keep information and documents that you gather during your decision-making process.

Medicare Needs Assessment

The answers to these questions can help you choose the Medicare coverage that may best fit 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, depending on your coverage.

  • 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 co-payment 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 2015 Part B deductible is $147.

The 2015 Part B monthly premium is $104.90 for most people.

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. You’ll want to look at your coverage choices carefully to make sure the care you need is covered 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))     ?

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. It’s a good idea to estimate what kinds of care and services you may need and how often you may need them. This information will help you compare how well different Medicare coverage choices may work for you. 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. You want to make sure you find a plan that covers the drugs you take. Sometimes a plan will cover a similar medication that you can substitute.

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.

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.

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.

What do you want to do next?

Or view Medicare plan examples