What Insurance Plan Should You Choose?

The open enrollment period for Medicare is from October 15 through December 7.  This means if you want to switch your Medicare plan, you have just under one week to do so.  Last week I saw a patient in the office who was very nervous regarding a potential switch.  She was so worried, that her blood pressure was elevated just thinking about it.  Her current situation is that she has traditional Medicare, and an additional supplement plan.  She was recently contacted by a company regarding a Medicare Advantage plan, with promises of cost savings for her.  Who doesn't want to save money?  She wanted to know my thoughts on her situation.  I told her to consider the following issues:

1.  Make sure your primary care doctor and all your specialists accept the potential plan you may switch to.  More so, make sure not only are they listed on the plan, but that they will keep you as a patient if you switch to the new plan.  You see, while some insurances are accepted by providers, they may have closed their panels to any new patients with certain plans.  So it isn't enough for the doctor's office to just take the insurance, but I would advise you to verify with the office manager that the physician will keep you as a patient if you switch to the new plan you are interested in.

2.  If there is a certain hospital close to your house, or that you are fond of, and you know that is the hospital you would want to go to should you need hospitalization, make sure that hospital is also on the new insurance plan.  The insurance company should verify this in writing for you (by showing you a list of hospitals and providers in their network).  Some plans may be inexpensive, but the only hospitals affiliated with the plan are the hospitals you may never want to go to.

3.  Are your current medications covered through the plan (either through the Medicare Advantage plan, or through a Part D plan)?  What will the co-pays be?  Does the plan insist you use a mail-order pharmacy?  Are you okay with that?  Is the formulary of medications that are covered limited?

4.  In addition to prices for medication, what are the co-pays for other services, such as office visits?  Some plans may have a very inexpensive medication formulary (such as all generic prescriptions are under $5), but the patient responsibility for services such as an outpatient CT scan is over $500.

5.  I would also inquire from any new plan how extensive is their network of medical specialists?  I have seen new insurers into my local market aggressively market their plans with low or no copays and inexpensive medications to gain market share.  However as soon as the patient requires a referral to a particular specialist, the plan might not have anybody in the network for me to send him to!

6.  Lastly, do you travel?  Are you a snow bird that lives in the north, but goes to Florida or Arizona in the winter?  If so, it would be wise to see if your plan is accepted in facilities out-of-state, and even if so, are there out-of-state network charges?  What would happen if there is a medical emergency and you required hospitalization in a hospital that isn't in your insurance network?

7.  If you require services such as physical therapy, what is the copayment for each session?  How does this fit into your budget?

8.  How much is a copayment to see your primary doctor?  How much more does it cost to see a specialist?

These issues above, coupled with monthly premiums, and costs of medications are what should guide you in deciding which plan is best for you.  The traditional Medicare product is accepted in nearly every hospital in the country, so that is the safest bet.  However, the Medicare Advantage plans may offer additional services like gym membership, dental, prescription drug coverage, nurse navigators to assist high risk patients, and other benefits.

Go to the Medicare website to read more about this enrollment period, and any other questions regarding Medicare.

Ultimately, the decision on an insurance plan is a cross between personal finance and personal relationships.  If a new plan covers your primary care physician, and you'll save a ton on medications, but your cardiologist isn't in network, you'll need to decide how vital your cardiologist is compared to a new guy who is in the network.  If you just saw the heart doctor due to chest pain, he ran a stress test that was negative, and he sees you yearly to check your blood pressure and cholesterol, then maybe there isn't a super strong bond.   But I'll bet if your cardiologist rushed you to the cath lab due to a heart attack, and successfully deployed a stent to restore blood flow, you'd probably want to stick with the guy who saved your life.  And that would be the right choice, even if it may cost you more.

If you have a story of how your insurance plan was really there for you, I'd love to read about it in the comments.   Likewise, if you were on a plan (whether or not it was a Medicare or Medicare Advantage plan) that disappointed you, please share your experience, too.  As a reminder, please do not divulge any personal health details coupled with personally identifying information, because if you do, it will no longer be personal, but rather quite public!