To evaluate a Medicare managed care plan of any type, it's important to get a complete written explanation of the plan's coverage, costs, and procedures. These are usually contained in a printed brochure called a Summary of Benefits. Also, get a chart showing premiums and copayments for each plan. If you do not understand exactly what the coverage, costs, and procedures are, ask a plan representative to point out where they are explained in the written information. If you can't get an important piece of information in writing, don't join the plan.
Then, compare the written information about the Medicare managed care plan with the following specific factors:
Choice of Doctors and Other Providers
For many people, the most important factor in choosing a Medicare managed care plan is whether the doctors, hospital, and other providers they already use and trust are in the plan's network of providers or, in case of fee-for-service plans, whether those providers regularly accept the plan's terms. If your hospital or doctors are not in the network, you will have to find new doctors, which is never an easy or comfortable process. Also, you might have to use a hospital that is more distant from your home.
The problem is not quite as great if the plan has a Point-of-Service Option (POS). (For an explanation of the POS option, read Nolo's article Medicare Managed Care Plans: An Alternative to Medigap Insurance.) PPOs and HMOs with POS permit you to use providers who are not in the plan's network if you make a higher copayment. However, if you are treated by non-network doctors very often, the extra payments may wind up canceling out the cost advantage of managed care.
With Medicare Advantage private fee-for-service plans, the decision is more difficult. With most of these plans, there is no network, so there is no simple, automatic way to know that the doctors and other providers you use will accept the plan for any particular treatment or service. Before joining one of these plans, talk directly with your primary care doctor and any other doctor or other provider you regularly receive care from. Ask them whether they have experience with the plan you are considering and if so, whether they often refuse to accept the plan's terms.
Access to Specialists and Preventive Care
The requirement that you must visit your primary care physician to obtain specialist referrals is one of the main objections to managed care. Try to learn how difficult it is to get a referral to a specialist with any plan you are considering.
Prescription Drug Coverage Under Medicare Part D
Deciding whether to remain in or join a Medicare managed care plan has gotten tricky since the introduction of prescription drug coverage under the Medicare Part D prescription drug program. Some managed care plans offer drug coverage that meets the Plan D standards, while others have dropped their drug coverage entirely.
If a plan includes Part D drug coverage, enrolling in that plan means that you are also enrolled in Part D. However, be certain that the plan covers the drugs you regularly take.
If a plan does not offer Part D coverage, you may need to enroll in Part D coverage elsewhere with a separate, stand-alone Part D prescription drug plan. For more information about Medicare Part D, see Nolo's article Medicare Part D Prescription Drug Coverage: The Basics.
Many Medicare managed care plans charge no premium to members. Other plans charge a relatively small premium -- especially PPOs, and HMOs with a point-of-service option or deluxe coverage, such as unlimited prescription drugs. Usually, these premiums are lower than for Medigap policies.
However, premiums don't tell the whole story. You must add up other costs -- such as copayments for doctor visits and prescription drugs -- to fully understand how much each plan is likely to cost you.
About 30% of Medicare managed care patients report having been denied coverage for treatments their plans deemed to be medically unnecessary or experimental. If you are denied coverage for a treatment or service, Medicare will not help you. The appeals procedure is run by the managed care plan.
Before joining any managed care plan, explore its appeal or review process. The procedures should be explained in the summary of benefits booklet the plan gives to potential members. If the review process is not fully explained, request written information from a plan representative.
Extent of Service Area
Consider the extent of a plan's service area, particularly if you live in a rural or spread-out suburban area. If the service area is not broad enough to include a good selection of specialists, you may find your future care choices limited.
Also, see whether the plan has what are called "extended service areas." Some plans permit you to arrange medical care far from your home if you travel frequently or spend a regular part of the year away from its primary service area. This allows you to take care of non-urgent medical needs, even if you are not at your primary residence.
Other Plan Features
Many managed care plans offer a variety of other features beyond basic Medicare coverage. Such benefits include: short-term custodial care, medical equipment, chiropractic care, acupuncture, acupressure, routine physical exams, foreign travel immunizations and emergency coverage, eye examinations and glasses, hearing tests and hearing aids, dental work, after-hours advice and treatment, chronic disease management, and wellness programs. If you are likely to use any of these benefits, the plan that offers them may be more attractive to you.
Where to Get Additional Information
Medicare managed care plans are available almost anywhere you live. Use the following resources to find the ones near you:
Medicare website. The Medicare website, at www.medicare.gov, allows you to find all of the Medicare managed care plans that serve your geographic area. (Look under "Health Drug Plans" for a link called "Compare Health Plans.") Always double check the information on the website, however, since it may be out of date or fail to mention how many seniors were dropped from the program over the last year.
SHIP. The State Health Insurance Assistance Program (SHIP) provides free counseling to seniors about Medicare managed care plans and Medigap. SHIP is funded by government grants and private donations; it has no connection to the health care or insurance industries.
SHIP staff knows how the plans and policies work and whether people in your area have had good or bad experiences with particular plans. To find the SHIP office nearest you, call the toll-free line for your state's central SHIP office, listed in the state government pages of the telephone book.
For an extensive discussion of managed care plans, along with guidance in choosing one that fits your needs, get Social Security, Medicare & Government Pensions: Get the Most Out of Your Retirement & Medical Benefits, by Joseph Matthews and Dorothy Matthews Berman (Nolo).