Questions to Ask

Because we have nothing to sell, we can hand you the questions a salesperson might rather you didn't ask. Bring them to a plan, an agent, or your own review. There's a print version so you can carry them.

Before you pick Original Medicare vs. Medicare Advantage

Ask yourself these — the answers tip the decision (see Choosing Coverage):

• Do I want to keep specific doctors, or the freedom to see any doctor who takes Medicare?
• Do I travel a lot or spend part of the year in another state?
• Would I rather pay a predictable premium (Original Medicare + Medigap) or a low premium with copays as I go (Medicare Advantage)?
• If my health declines, do I want to be sure I can keep my coverage without switching? (Remember the Medigap "one-way door".)
• Which specific drugs do I take, and how are they covered under each option?

About any Medicare Advantage plan you're considering

These get past the brochure. Ask the plan directly:

• Are my doctors and hospitals in the network — this year and next year?
• Which of the services I actually use require prior authorization (pre-approval)?
• What is the annual out-of-pocket maximum, and what counts toward it?
• Do I need a referral to see a specialist?
• Are all of my medications on the drug list, at what tier, and with what restrictions?
• What is the plan's Star Rating, and how many complaints does it get?
• What is covered if I need care while traveling or if I move?
• What is changing next year? (Ask to see the Annual Notice of Change.)

About a Medigap (Supplement) policy

• Is this the exact standardized Plan [letter]? (If so, every insurer's version is identical — so I'm only comparing price and service.)
• What is the premium, and how have this company's premiums increased in past years?
• How does the company set rates — by age, or the same for everyone?
• Am I inside my one-time guaranteed-issue window, or will I face health questions? (See Medigap.)
• Is there a household or other discount?

When an agent or broker contacts you

• Which plans in my area do you not offer or represent?
• How are you paid, and does it differ between the plans you're showing me?
• Are you recording this call, and did I agree to a Scope of Appointment for what we're discussing?
• Will you compare this against Original Medicare and a supplement, not just Advantage plans?
• Can you put the specifics — my drugs, my doctors, the costs — in writing?

For unbiased help with no sales incentive, a SHIP counselor answers all of this for free.

About a Part D drug plan

• Is every drug I take on the plan's list (formulary), and at what tier (cost level)?
• Does any of my drugs need prior authorization, step therapy, or have quantity limits?
• Is my pharmacy a "preferred" pharmacy, and would mail order cost less?
• What happens to my costs across the year as I fill prescriptions? (See Part D.)

When a claim or service is denied

• What is the exact reason for the denial, and which coverage rule or criteria did you apply?
• What is my deadline to appeal, and how do I file?
• Can I get a fast (expedited) appeal because my health is at risk?
• What information would change this decision, and who can help me appeal? (See How Do I… and Appeals timelines.)

About Medicaid and your state

• Which eligibility pathway do I qualify under, and what's my income/asset test? (See Medicaid Eligibility.)
• When is my renewal date, and how will you contact me? (Keep your address current.)
• Is my coverage through a managed care plan, and are my doctors in it?
• If I have Medicare too, how do the two work together for me? (See Dual Eligible.)