Question 1 – Are My Doctors in the Network of the Medicare Plan?
This is a big one, especially if you have a health condition. If your doctor does not accept your plan you will probably wind up paying the full price for his or her services.
When checking to see if your doctors are in the network for your plan, don’t make this common mistake. Don’t ask someone in the doctor’s office.
They will probably know if your doctor is in a network for a given insurer. However, they will often assume that if your doctor accepts XYZ insurance company, your doctor accepts every plan from that insurer. The safest way to check is to visit your insurer’s website. Just make sure that you search the network for the specific plan you are thinking about buying.
Question 2 – Are my Prescriptions Covered by the Medicare Plan?
No insurer covers all drugs. You will need to check their formulary (their list of prescription drugs) to make sure that your prescriptions are covered by any plan you are considering.
If you really like the plan but it doesn’t cover all of your prescriptions, you don’t need to rule it out automatically. There is a chance that your doctor can change your prescription to something that is listed in the formulary. The formulary may include a similar drug.
Question 3 – What Will My Cost Shares Be?
Cost shares are deductibles, copays and coinsurance. Knowing what you will pay when you visit your doctor, have an x-ray or visit the emergency room is an important part in gathering the information you need to make an informed decision about your coverage.
A deductible is generally paid only once per policy year. So, if your plan has a deductible that applies for hospital stays and you are in the hospital in January and again in March of the same year, you will pay your deductible once unless the cost of your visit was less than the amount of your deductible. In the unlikely event that your first hospital stay cost less than the amount of the deductible, you would pay only the remainder of the deductible for your second hospital stay.
Some plans will have copays or coinsurance that is paid in addition to the deductible for certain services
Some plans will have one deductible for drugs and another for medical expense. Some have one or the other. Some have neither.
A copay is usually a small dollar amount that you had the doctor’s office before each visit or hand your pharmacist for each prescription refill. However, you will sometimes see copays for hospital stays. These aren’t usually small amounts. While you may pay a $20 dollar copay for each doctor visit, if your plan has a hospital copay, you may pay $400 per day for the first 5 days in the hospital.
Coinsurance is when your cost-share is expressed as a percentage. If your contract says that you have to pay 20% of the cost of a doctor’s visit, they are referring to coinsurance.
Question 4 – How much will this plan cost?
Last and perhaps least important is the monthly cost of the policy. I say least because your cost for doctor visits, drugs and cost shares could be much higher than the monthly cost of the policy.
So, make sure that you know:
- If your doctor is in the plan’s network
- If your prescriptions are in the formulary
- What your cost shares will be (deductible, copays, coinsurance)
- What your monthly premium will be.
Once you know the answer to these questions, you will be much better prepared to select a policy whether you do this on your own or if you enlist the aid of an insurance agent.