Understanding your health care needs will 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 your health care. It’s important to take the time to truly 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 where you can keep them along with other information and documents that you gather during your decision-making process.
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Medicare needs assessment
The answers to these questions can help you decide which kind of Medicare plan is right for you.
Frequent doctor visits can get costly, depending on your coverage. With Original Medicare, you pay 20% of the doctor’s fee for most doctor services. With most Medicare Advantage plans, you pay a small copayment for each visit.
Many Medicare Advantage plans contract with a network of providers and pharmacies to get special pricing. Plan members 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 significantly more for the same care and services.
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.
People with ESRD generally can’t join a Medicare Advantage plan and must stay with Original Medicare.
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.
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 will 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.
Many people who have employer or union health insurance join Medicare Part A and refuse Part B. Part A is premium free 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 Enrollment Period. Also, you can delay getting prescription drug coverage without penalty if you have creditable coverage.
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.
Many Medicare Advantage plans contract with a network of providers and pharmacies within a geographic service area to get special pricing. Plan members pay less out-of-pocket for care and services they receive from network providers. You’ll pay more if you need services while traveling. Original Medicare provides coverage nationwide.
Medicare limits the number of days it will cover. You’ll need to figure out whether your care will be covered under different plan choices, for how long and at what price.
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.
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.