How to Choose the Right Medicare Plan
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Consumer Reports has no financial relationship with advertisers on this site.
By now you’re probably noticing the signs of fall: crisper temperatures, pumpkin-spice lattes, and, if you’re over 65, an onslaught of advertisements and advisories about Medicare.
Open enrollment season starts on Oct. 15 and runs through Dec. 7. For those who have traditional Medicare (Parts A and B), this is your annual opportunity to change or switch your Part D drug plan. And for those with Medicare Advantage, you can switch to a different version of that plan—or you can switch to it from traditional Medicare and vice versa.
(If you're signing up for Medicare for the first time, you follow a different schedule. To avoid a late enrollment fee, you must sign up during the 7-month period around your 65th birthday; get more details on signing up for Medicare.)
Even if you’ve been satisfied with your current coverage, you should still make the effort to explore what’s new and different. In advance of open enrollment, the Centers for Medicare and Medicaid Services (CMS) has announced important changes to both Medicare Advantage and Part D plans for next year.
What’s more, each year insurance companies make changes to drug formularies, provider networks, copays, and more. Your health needs—the doctors you visit or the medications you take—may be different this year, too.
“If you don’t take time to make sure you still have the appropriate plan, you could end up spending more than you need to—or not getting the coverage you need,” says Fred Riccardi, vice president of client services at the Medicare Rights Center, a consumer service organization.
Here's what you need to know to make the most cost-effective choice for your Medicare coverage in 2019:
Medicare Advantage Looks More Enticing
This year, there are more reasons to consider Medicare Advantage plans, which are run by private insurers that offer coverage through HMOs or PPOs. Premiums for Medicare Advantage will decline by an average of 6 percent in 2019, while the number of new benefits available will increase, according to the CMS.
In addition to including vision, dental care, and drug coverage, Medicare Advantage plans will now be able to offer other health-related benefits, including adult day care, home-health aids, and home-safety modifications, such as grab bars and wheelchair ramps. Those services are not generally covered under traditional Medicare. (You can find out more about the pros and cons of these plans here.)
Another change: You’ll have more time to test drive your Medicare Advantage choice to make sure it works for you: There’s a “disenrollment period,” when you can drop the plan you’ve chosen and either switch to another Medicare Advantage plan or enroll in traditional Medicare and, if you choose, get a Part D plan. Beginning in 2019, the disenrollment period is being extended from its current six weeks to three full months, from Jan. 1 to March 31.
But These Plans Have Drawbacks
Low premium costs and the all-in-one simplicity of Medicare Advantage plans can be appealing. The number of people choosing this option is expected to climb to 37 percent in 2019, up from 33 percent in 2017, according to the CMS.
Still, Medicare Advantage plans do have significant shortcomings: In a new report (PDF) from the U.S. Health and Human Services’ Office of Inspector General, federal auditors cited “widespread and persistent problems" related to denials of care and payment in these plans.
The report also raised concerns that the insurers, who collect a fixed fee from the government for taking care of Medicare patients, have an incentive to "deny preauthorization of services for beneficiaries, and payments to providers, in order to increase profits."
Another caveat: If you enroll in Medicare Advantage, you may have a hard time getting supplemental Medigap coverage if you later decide you want to switch to traditional Medicare.
Under federal law, insurers cannot deny you Medigap insurance when you initially enroll in Medicare at age 65, and they must renew your coverage annually as long as you pay your premiums. But if you try to buy Medigap insurance outside of that initial enrollment period, insurers in many states can deny coverage or charge you higher premiums based on your health or pre-existing conditions.
Low Premium Costs Can Be Misleading
Perhaps the biggest selling point of Medicare Advantage is that the premium costs often seem low, with some plans advertising $0 premium policies. But focusing on low monthly premiums alone is a mistake.
“There might be trade-offs that could result in higher out-of-pocket costs," says Mary Johnson, a Medicare policy analyst with The Senior Citizens League, a nonpartisan senior advocacy organization.
A better strategy is to estimate your total out-of-pocket costs under the plan. Take a look at your past medical needs and consider what care you might need in the year ahead. Then add up the copays, deductibles, and coinsurance payments you are likely to pay. Your insurer may have an online cost estimator tool that may help, and you can find more resources here. Don't forget to do a separate calculation for your prescription drug costs; more on that below.
Investigate Before Enrolling
If, after weighing the pros and cons, you ultimately decide that Medicare Advantage is your preferred choice, you will need to decide whether to stay with your current plan or switch to another offering.
Your first step is to check your current plan's offerings for 2019. Look at the details in the “annual notice of change," which your insurer should have sent to you in September; you can also call your insurer or go to its website to get the information. Then use the Medicare Plan Finder tool or call Medicare to find out what other plans are available in your area and compare them.
Once you know which plan looks most promising, dig into the details—you want to make sure your medical treatment will actually be covered. Call the insurance companies, or check their websites, to learn what doctors and hospitals are in the plan’s network. Then double-check this information by calling your healthcare providers directly to make sure they’re still participating.
To avoid surprise medical bills, be sure to investigate what happens if you use an out-of-network provider, as well as what the referrals and preauthorizations you will need to see a specialist. And find out whether, and how, you’ll be covered if you’re traveling out of your coverage area.
Review Your Drug Coverage
If you’re among the 72 percent of Medicare beneficiaries enrolled in a drug plan, whether a stand-alone Part D plan or a Medicare Advantage policy, it's worthwhile to evaluate your current coverage. As with your medical plan, you should have received a detailed breakdown of changes for 2019 from your insurer. You can also compare your drug plan with other options by using the Medicare Plan Finder tool.
CMS projections show that the average basic premium for a Medicare Part D prescription drug plan will fall to $32.50 per month next year from its current $33.59. But here, too, you need to look beyond the premiums to determine your total costs: Make a list of your prescription medications, then check out your plan’s formularies to make sure your drugs are covered and to learn which tier your drugs are in. (The higher the tier, the higher your copay.) And look at the costs of deductibles and coinsurance, especially if you’re taking expensive specialty drugs.
Even if your prescriptions are covered, there may be hurdles to accessing them, so check the plan's rules now. In 2019 Medicare Advantage plans will be allowed to require “step therapy,” which means, in certain cases, you’ll need to try a less expensive drug before you'll be covered for a more expensive one. Or you may be steered toward a preferred pharmacy instead of your local drugstore.
Reliable Help Is Available
With all the information about Medicare coming your way during open enrollment, assessing your coverage and finding the best plan can be confusing. “It can be daunting to sort through the advertising and sales pitches, but there are resources available for unbiased advice and information,” says Jane Sung, a senior strategic policy adviser at the AARP Public Policy Institute.
Again, a good starting point is the Medicare Plan Finder tool. Medicare also offers enrollees an online-chat feature for some beneficiaries where you can connect with Medicare experts to ask questions about your coverage options.
The Medicare Rights Center has an interactive tool that provides easy-to-use information about enrollment and plan options. And if you want state-specific details, the State Health Insurance Assistance Program (SHIP) can tell you more about offerings in your area. To find your state’s SHIP program, go to Shiptacenter.org or call 877-839-2675 to talk to a trained counselor.
People who are struggling to pay bills may be able to get help through the Medicare Savings Program. To find out whether you’re eligible, go to benefitscheckup.org, or contact your local Medicare Savings Program office.
If you end up staying with the status quo, you don’t need to do anything: You’ll be automatically re-enrolled. But if you’re switching plans, make sure to do so by Dec. 7 by calling Medicare at 1-800-MEDICARE or going to medicare.gov. New coverage goes into effect on Jan. 1.
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