When evaluating Medicare options, the advertised premium is only one piece of the puzzle. The real cost of a plan emerges when you start using it — through copayments, coinsurance, deductibles, network restrictions, and prior authorization requirements. Before you enroll, consider asking these eight questions about every plan you evaluate.
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1. Are my doctors and hospitals in network?
If you have established relationships with specific physicians or specialists, verify that they participate in the plan's network. HMO plans generally require in-network care, while PPO plans may allow out-of-network access at higher cost.
2. What will I pay for specialists, imaging, outpatient surgery, and hospital care?
Look beyond the premium. Review the plan's Summary of Benefits to understand copayments, coinsurance, and deductibles for each type of service you may use.
3. What is the annual out-of-pocket maximum?
Medicare Advantage plans have a yearly out-of-pocket limit for covered Part A and Part B services. Original Medicare by itself does not have a yearly out-of-pocket maximum, although supplemental coverage can limit exposure.
4. Which services require prior authorization or referrals?
Certain tests, services, or supplies may require plan approval before coverage. Ask the plan which services require authorization and what the typical review timeline is.
5. Are my prescriptions covered, and at what tier?
Check the plan's formulary to see if your medications are covered and what tier they are placed on. Tier placement affects your out-of-pocket cost for each prescription.
6. What happens when I travel or live in another state?
Some plans limit coverage to specific geographic service areas. If you travel frequently or split time between states, understand how each plan handles out-of-area care.
7. Could I obtain Medigap later, or would underwriting apply?
During the one-time six-month Medigap Open Enrollment Period, insurers generally cannot deny coverage because of pre-existing conditions. Outside that window, medical underwriting may apply in many states.
8. Can I afford premiums if they increase?
Both Medicare Advantage and Medigap premiums may change over time. Consider whether your retirement budget can accommodate potential premium increases in future years.
Get Personalized Help
Compare plans at Medicare.gov. Get free, unbiased counseling from your State Health Insurance Assistance Program (SHIP) at SHIPhelp.org.
This article is for educational purposes only and does not constitute medical, legal, insurance, or financial advice. Costs, benefits, networks, and eligibility vary by plan, insurer, and location.