How to find coverage that's right for you
A couple decades ago, there weren't a lot of choices when you became eligible for Medicare. Most U.S. citizens enrolled in Original Medicare, the health plan that's provided by the U.S. government. The decision-making process was pretty easy.
In recent years, in most areas the Medicare marketplace has exploded with choices. Most people now have a wide selection of private Medicare Advantage and Part D drug plans to choose from—in addition to Original Medicare and Medicare supplement (Medigap) plans.
How do you decide which plan best meets your health care needs, preferences, and budget? Here are 7 things to consider: what's covered, cost, provider network, prescription drugs, other benefits, care when you travel, and quality rating.
If you're only looking for basic, no-frills coverage, Original Medicare takes care of that. It's the combination of Medicare Part A (hospital insurance) and Part B (medical insurance). To get help paying for prescription medications, you'll also need to enroll in a stand-alone Part D (prescription drug) plan.
Medicare Advantage plans, also known as Medicare Part C, combine Parts A and B, and often Part D (also known as Medicare Advantage Prescription Drug plans). These plans may include vision, hearing, and dental benefits, and health and wellness programs that aren't offered by Original Medicare. Medicare Advantage plans are an alternative to Original Medicare, not a supplement to it.
Even if you don't use many health care services or prescription medications at the moment, keep in mind that even the healthiest person can experience an unexpected illness or accident, and costs can add up fast. Prepare for the unknown as you choose a plan, just in case.
Look carefully at the costs of each plan, including premiums, deductibles, copays, and coinsurance. Then look a little further.
How much will you pay for X-rays, outpatient surgery, inpatient hospital care, and other services you may need? Is there a yearly limit on what you pay out-of-pocket?
What makes the most sense given your health and financial situation?
With Original Medicare, you can see any doctor who accepts Medicare. With most Medicare Advantage plans, you'll need to use doctors, hospitals, and other facilities in the plan's network.
If you're considering a Medicare Advantage plan, check the provider directory to see if your doctor is in the plan's network, or consider whether you're willing to switch doctors. Also find out if you can see a non-network doctor if you choose, and how much you'll pay if you do so.
Each health plan that offers prescription drug coverage will include a drug formulary, which is the list of medications the plan covers. Are the medications you're currently taking listed on the formulary?
How much will you pay for brand-name drugs, and how much for generic drugs? Does the plan require that you get prior authorization, or meet other requirements, before your medications are covered?
And are network pharmacies conveniently located for you?
Check to see if the plan provides fitness or dental benefits, vision care, or hearing-aid coverage. You won't find that coverage with Original Medicare, but it's often included as part of Medicare Advantage plans or is an optional add-on.
With Original Medicare, you can travel anywhere in the United States and its territories and get the medical care you need from any doctor or hospital that accepts Medicare. Medicare Advantage plans may not cover your care in the United States outside of the plan's service area, with the exception of emergency and urgently needed care.
Outside of the United States, Original Medicare covers services in a few, limited instances.
Many Medicare Advantage plans provide broader coverage, such as emergency and urgent care worldwide.
Check each plan carefully to see what rules and costs apply.
The Centers for Medicare & Medicaid Services (CMS) evaluates the quality of Medicare Advantage plans every year and their ratings give you an apples-to-apples way to compare plans. A 5-star rating indicates the highest rated plan, and a 4-star rating means an above-average plan.
You'll find the most up-to-date star ratings on the Medicare Plan Finder tool. The 5-star plans have a gold star near their names. Or you can call 1-800-MEDICARE, (1-800-633-4227, TTY 1-877-486-2048), 24 hours a day, 7 days a week.
For more details about what the different types of Medicare plans do and don't include, check out our Understanding Medicare page.
Learn about Medicare plans for group, state, and federal employees
If you are becoming eligible for Medicare and your employer offers a group retiree Medicare Advantage health plan through Kaiser Permanente Washington, call us at 1-800-581-8252 or TTY WA Relay 711, from 8 a.m. to 5 p.m., Monday through Friday.
PEBB and FEHB members can also find information online:
Medicare Star Quality Ratings
Our Medicare Advantage health plan in Washington was rated 4.5 out of 5 Stars for 2019. Our 4.5 out of 5 Star rating is based on quality, service, and member satisfaction, so you get the peace of mind that comes with knowing you're getting high-quality care. 2