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SeniorLAW Publications on Medicare Part D

Below are some things you may want to consider when looking at the different plans that may become available.

• Are you willing to give up your traditional Medicare?   To enroll in any Medicare Advantage plan, you will give up your coverage under traditional Medicare.   This is something you should carefully consider before making any decisions.
• Are you willing to give up your Medicare Supplemental Insurance policy, also called a "Medigap" policy?
• Does your supplemental insurance policy cover additional benefits not found in a Medicare Advantage plan.
• If you give up your Medigap policy, would you be able to receive another Medigap insurance policy in the future?   Would it have the same benefits?   Would it be the same price?

 

Questions to ask about your primary care doctor and specialists:

• Does your current primary care doctor or specialist participate in the  Medicare Advantage plan?
• If your current doctor does not participate in the Medicare Advantage plan, are you willing to change doctors?
• If you do not have a current physician, who are the physicians that participate in the plan?  What are their qualifications?   Are there a variety of fields available as primary care physicians (internist, general practitioner, OB-GYN, etc)?
• If you are in a Medicare Advantage plan, can you change doctors within the Medicare Advantage plan and, if so, when?
• If you want to see a doctor or specialist, do you need prior authorization or a referral?   If so, how does that process work?  Is your primary physician willing to make all the necessary referrals?
• Can you see doctors but of the plan's provider network?   If so, are there higher costs to you?

 

• If you travel, does the plan have providers and facilities in other geographic areas that you may need?   Can you use these when you are out of your service area?
• Are your Medicare Advantage plan's care facilities conveniently located?
• Where do you need to go in case you have emergency care needs?   What if an emergency arises when you are out of the plan's service area?   How long will your plan cover out-of-care after the immediate danger has passed?
• What hospitals can you go to and still be covered by the Medicare Advantage plan?
• What will happen if you travel out of the plan's service area?   If you spend time traveling, a plan with a limited service area would not be a good idea unless you have additional insurance to cover you or unless the plan will coordinate coverage with one of its affiliates in the area where you are traveling.
• What costs and copayments are you responsible for under the Medicare Advantage plan?
• How does the plan provide coverage?   Are there doctors in the plan that actually provide the services to you, or does the plan simply reimburse you (or your provider) for services you receive?

 

Note: All Medicare Advantage plans must cover the same services that Medicare would cover.  This could be either in the form of services or payments.  MSA plans will have a high deductible, but, after it is met, they must cover Medicare-covered services.

• What services does the Medicare Advantage plan cover?  If the plan offers additional services, is there an extra charge for this?  Is this package optional or mandatory?  (Note: Plans can offer packages containing additional benefits for a cost.  Furthermore, plans can require that you buy an extra package in order to enroll in the basic plan itself).
• How much coverage do you receive for preventive services under the Medicare Advantage plan?
• If you are currently receiving treatment, are all of the services you need covered by the Medicare Advantage plan?   If not, what alternatives are available to you?   Are the alternatives acceptable to you and your physician?

Things to ask about the Medicare Advantage plan membership:

• What is the Medicare Advantage plan's record in your community?   Have there been complaints about the plan?   If so, how were they resolved?   For further information on the Medicare Advantage plan's record in your community, you may want to contact the Office of the Commissioner of Insurance.
• How many Medicare Advantage plan members withdrew from that particular Medicare Advantage plan in the last year?   How many physicians withdrew from the plan?
• Can the Medicare Advantage plan cancel your membership and, if so, how, when, and why can it do this?
• How does the plan handle customer complaints, grievances, and appeals?

 

Long-term care (such as skilled nursing facilities) and Medicare Advantage plans:

• Are there any long-term care facilities in your community that are part of a Medicare Advantage plan network?
• Do you like the nursing homes that are part of the plan's network?   Are they near to your home or your family?   Have there been any complaints about these nursing homes?   If they are full, where will your plan send you?
• What prior authorization is required and how long does it take to process this information?
• How often can your primary care physician visit you at your long-term care facility and be covered under the Medicare Advantage plan?
• If you want to change plans, do any labs and pharmacies participate with both your facility and your Medicare Advantage plan?
• Which home health care agencies are part of the plan's network?   Do you like these home health care agencies?   Have there been any complaints about these agencies?   How often can you receive home health care services under the plan?   Are there any co-payments or deductibles for home health care services?

 

Things to consider if you are a resident of a long-term care facility and you want to change plans:

• How will the change in plans affect your current living situation?   Would you be required to change facilities?
• Does your long-term care facility know the proper billing process for all your health care services?
• If you change plans, will your doctor be able to visit you in your current long-term care facility?  Is your current doctor part of the new plan?

Things to consider if you are thinking about a Medicare Advantage MSA: 

• Can you afford to pay at least $6,000 out of pocket for your medical expenses?  You will need to satisfy this deductible before your Medicare Advantage MSA plan will provide coverage.   Also, even after meeting this deductible you will have to pay out of pocket for medical services that Medicare would not have covered, such as prescriptions.   CMS will put money in your MSA but there is no guarantee how much that will be.
• Are you ready to give up your traditional Medicare coverage?   You will need to do this in order to enroll in a Medicare Advantage MSA (or any Medicare Advantage plan, for that matter.)
• Will there be any tax advantage to you by enrolling in a Medicare Advantage MSA?  Speak to your accountant or a financial advisor about this.
• Will you be outside of the United States for 182 days or more?   If so, you will be ineligible for a Medicare Advantage MSA plan.
• Do you presently have Medical Assistance (also called "Medicaid" or "Title 19"), QMB or SLMB coverage?  Are you already insured by your employer?
• Persons with Medical Assistance, QMB, SLMB, Federal Employee health benefit or VA benefits are not eligible for Medicare Advantage MSA plans.
• Will you have to give up your other health insurance?   Are there any benefits to having Medical Assistance and a Medicare Advantage plan?

• Medicare Advantage Introduction
• Things you should consider before enrolling
• Types of Medicare
• Appeals & Grievances
• Glossary
• Medicare Advantage Know Your Rights
• Link to State of Wisconsin's Online Medicare Supplement Book