By asking the right questions about Medicare, you can avoid unexpected costs and penalties. These considerations will also guide you as you choose the Medicare plan that best suits your health needs and lifestyle.
Comparing Medicare vs. Medicare Advantage: Questions to Ask During Open Enrollment
Common Medicare Annual Enrollment Period Questions
To help you evaluate your coverage options before your enrollment period begins, we’ve compiled seven questions below that act as a step-by-step checklist to help you find the best health insurance plan for your needs and budget.
1. When Is Medicare Open Enrollment?
While the annual fall open enrollment is typically what people think of when talking about Medicare enrollment periods, there are actually several times when you can sign up for or make changes to Medicare coverage. Missing these windows can result in late enrollment penalties
Use the timeline checklist below to track your enrollment windows and avoid any costly mistakes:
[READ: Medicare Enrollment Deadlines: When Can You Sign Up?]
2. Do All of My Doctors Accept Medicare?
When you’re choosing a plan, look closely at the plan’s network restriction. Seeing an out-of-network doctor
versus one available within your plan’s network can affect any out-of-pocket costs you may have to pay.
Medicare
With original Medicare (Part A and Part B), there are basically three types of providers, says Joel Mekler, a health benefits professional, Medicare expert and writer of the “Medicare Moments” weekly column in the New Castle (Pennsylvania) News. These providers are:
— Participating. These providers “accept assignment,” meaning they agree to charge only the amount that Medicare allows for services.
— Nonparticipating. These registered Medicare providers choose not to accept assignment, which means they can bill the patient the difference between what they charged and what the insurance company paid. This bill can be “up to 15% above the amount that Medicare will pay,” Mekler says.
— Opt-out. These providers will not accept Medicare at all. If you want to see a physician who has opted out of Medicare, you will need to pay out of pocket for all of your medical care.
Medicare Advantage
While you can see any doctor with Medicare (though you may pay more to see out-of-network providers), most Medicare Advantage plans come with specific network restrictions. You’ll need to ensure your provider and hospital are in-network.
“If they are not, you need to know if it’s possible to see doctors beyond the specific network or not,” Hopkins points out.
However, there is some flexibility with Medicare Advantage plans. All Medicare Advantage plans are either preferred provider organizations (PPO) or health maintenance organizations (HMO).
“Although a Medicare PPO is a little more expensive, it allows for a larger network,” Mekler says. “In other words, with a PPO, somebody could go in or out of the plan’s network. Unlike with an HMO, you won’t need a referral from your primary care doctor to see a specialist if you have a PPO.”
[Read: How to Choose the Best Medicare Advantage Plan]
3. Do You Have Any Expensive Procedures or Tests Coming Up?
If you have health issues or you know that you’ll need expensive tests and procedures in the next year, you should think about deductibles when choosing your Medicare plan. Choosing a plan with higher premiums but lower deductibles and out-of-pocket costs for hospitalization may be the most sensible choice.
On the other hand, if you’re not anticipating any changes in your health needs, sticking with a lower-premium plan — such as a Medicare Advantage plan with a $0 premium — may be a better bet.
“A good candidate (for Medicare Advantage) is someone who can understand the rules and embrace them,” notes Barbara Hopkins, a Portland, Maine-based, self-employed Medicare educator with nearly 30 years of experience in health payer operations. “Second of all, if they have not had huge health problems up until the point of being 65, they’re going to be a pretty good candidate because it costs less to join a Medicare Advantage plan, and chances are they are going to be using less expensive services.”
[READ: Does Medicare Cover Innovative Treatments?]
4. Are Telehealth Services Covered?
Most telehealth flexibilities — which had been expanded during the COVID-19 pandemic — have been extended through December 31, 2027. Medicare beneficiaries can continue to receive specific services and treatments at home, such as:
— Substance abuse treatment
— Some mental health care services
— Some stroke-related care services
— Monthly end-stage renal disease visits for home dialysis
Starting January 1, 2028, many Medicare beneficiaries — specifically those who don’t reside in a designated rural area — will no longer have the option to see a provider via a remote telehealth visit.
5. How Much Do I Want the Extra Perks?
Medicare Advantage offers perks that original Medicare doesn’t, such as coverage for dentures, eyeglasses and fitness benefits, like SilverSneakers. However, you may need to pay extra for some of these perks or accept additional premiums.
Shub Debgupta, founder and CEO at Predict Health, a health care analytics company in Arlington, Virginia, says that some innovative perks to reduce social isolation or improve living conditions that can affect health are becoming more commonplace among Medicare Advantage plans. Beneficiaries who are eligible for both Medicare and Medicaid, for instance, might receive assistance with air conditioning or air filters for their homes.
Debgupta also believes that technology support will become a more popular perk offered by Medicare Advantage plans in the near future. Financial planning is another Medicare Advantage perk quickly gaining steam, he adds.
6. How Do I File an Appeal if Service Coverage Is Denied?
Although many seniors find the benefits offered by Medicare Advantage plans very appealing, eligible individuals should know that an April 2022 report from the inspector general’s office found that some Medicare Advantage insurance providers denied care or payment for care that would have been covered under original Medicare. In fact, 13% of the instances of denied prior authorization by Medicare Advantage providers met the eligibility requirements of original Medicare.
Debgupta says that it’s vital for people who have a claim denied to understand their rights of appeal.
“When people do appeal or refile, the second refiling acceptance rate is in the 90s. Some of those (denials) are primarily paperwork glitches. The majority of appeals get accepted,” he notes.
7. Does the Medicare Plan Cover Prescription Drugs?
Medicare drug coverage, Part D, helps pay for prescription medications, though this coverage is optional. It’s important to note that if you don’t sign up for drug coverage when you first enroll in Medicare and you don’t have other coverage at the time, you’ll need to pay a late penalty for the entire time that you are on Medicare.
You can add a Medicare drug plan if you have original Medicare or a Medicare Advantage plan, though Medicare Advantage plans often include drug coverage.
All plans are required to cover a wide range of commonly prescribed medications. Each plan has a different formulary, which lists what medications are covered. The formulary must include no fewer than two drugs in each of the most commonly prescribed drug classes.
By looking at your medical history, taking stock of your health savings account and reviewing the doctors that you see most often, as well as the medications that you take, you’ll be equipped to make a wise decision when you sign up for or adjust your existing Medicare coverage. When it comes to health care, knowledge truly is power.
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7 Questions to Ask During Medicare Open Enrollment originally appeared on usnews.com
Update 06/16/26: This story was published at an earlier date and has been updated with new information.
