Friday, October 23, 2015


Selecting the right
Medicare plan for you


First things first: FINDING PLANS IN YOUR AREA.

The best source of approved Medicare plans in your geographic area is the web site:


Q1: Do you have a specific physician - primary care or specialists - that you feel you must have?

If YES, then compare only those plans that include that physician.

    The easiest way to find out is to call the plan's toll-free number and ask: "Is Dr. (insert name) on the providers' list?"

Lesson learned the hard way Ask if the primary care physician (PCP) is capitated. That means while a doctor you want to see may be on the plan's Provider List (more on that later), the PCP may be limited to only a few of the practitioners on the list; if the doctor you want is not on the particular PCP's list, you cannot be referred to that doctor; referrals are allowed only to those practitioners on the PCP's personal list.

Q2. Do you have any specific medications that have no substitutes?

Check with a PHARMACIST - not a doctor or nurse - about alternatives for the medication you are taking. Pharmacists usually know better than doctors, nurses, pharmacy reps, and your Great Aunt Tillie when it comes to medicines.

If YES, check with the plans you like to assure the plan's FORMULARY (drug list) includes the drug(s) you are taking. Also check the drug's LEVEL (typically 1 through 4; each level being more expensive) and what your co-pay will be for a 30-day and 90-day supply.

    The easiest way to find out is to call the plan's toll-free number and ask: "Is drug (insert name) on the formulary?"

Q3. What are hospital in-patient costs? Some plans have $0 co-pays for the first "n" days with $100 or greater co-pays for the next "n" number of days; other plans charge (relatively) high co-pays of $250 or more for the "n" initial days then $0 for the remaining days.

Since I've been on Medicare I have been hospitalized three (3) times (for surgeries). My maximum time-in-hospital was 5 days. My plan has the first five days free (no co-pay); my co-pay bill for all three surgeries combined was $0.00.

    The easiest way to find out is to call the plan's toll-free number and ask: "What are the in-patient co-pays?"

SOME providers provide easy access to this information from their Web site. Others force prospective clients to call a toll-free number and hope the information received is accurate. Get hard copy documentation to be safe and sure.

Keep in mind that you and the plan are "stuck" with each other for the full plan year. You normally can change PCPs every month, but you normally cannot change to a different plan.


There are three (3) documents you want to see, preferably BEFORE you make a decision:

    1. EVIDENCE OF COVERAGE: The evidence of Coverage follows Medicare's list of benefits and adds the plan provider's additional benefits. This is the "bible" of the plan; it is approved by Medicare and cannot be modified during the plan year. It is subject to change ONLY for the coming plan year. (If you sign up for a 2016 plan, it won't be subject to change until 2017.)

    2. PROVIDERS' LIST: This is a list of physicians, hospitals, clinics, therapists, etc. that have contracts with the plan. This list IS "subject to change," but for the most part whoever/whatever is on the list when it initially was published remains on the list through the plan year.

    3. FORMULARY: This lists all the prescription medications the plan covers. Like the PROVIDERS' LIST, it is "subject to change," but change rarely occurs in mid-year.

    NOTE There are several plan types in two plan categories.

    The categories are Advantage plans and Supplement plans. Many excellent Advantage plans cost no more than what the Medicare recipient pays already. Medicare Supplement plans typically charge an additional fee. Supplement plans often have no restrictions on providers or locations and may be a better option for travelers. (Some Advantage plans have "worldwide" coverage, but there are conditions.)

    The two sub-options are "with drugs" and "sans drugs." There also are "drugs only" (Part D) plans.

    What plan is best suited to each individual is determined only by that individual.

No comments: