Tips on Choosing a Medicare Managed Care Plan


Make sure a Medicare managed care plan meets your needs before you sign on the dotted line.

To evaluate a Medicare managed care plan, get a complete written explanation of its 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. Compare that written information with each important category discussed in this article.

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.

It's important to look at a number of specific factors when evaluating a managed care plan.

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. 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. And you might have to use a hospital that is more distant from your home.

The problem is not quite as great with PPOs or HMOs with a Point-of-Service Option (POS) as it is with regular HMOs. PPOs and HMOs with POS permit you to use providers who are not in the plan's network. So, if you want to continue with a particular doctor or provider who is not in the network, you may do so, but with a higher copayment each time you use the non-network provider. 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.

Access to Specialists and Preventive Care

The requirement that you must visit your primary care physician to obtain specialist referrals is one of people's 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. But 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.

Total Cost

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. But premiums don't tell the whole story. You must add up other costs — such as copayments for doctor visits and prescription drugs — to see whether a plan is worth your dime.

Review Process

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. The prospect of having your wishes and those of your doctor overruled by the insurance company is always enraging. And when the treatment is for a serious illness, the plan's rejection can be devastating.

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

Useful sources of information about managed care plans are available almost anywhere you live. One is Medicare's website at Look under "Plan Choices" for a link called "Medicare Personal Plan Finder," which allows you to find all the Medicare managed care plans that serve your geographic area. The information includes the outlines of each plan and its costs, as well as the address and phone number of the plan's representative in your area. 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.

Another great help to seniors trying to sort out the managed care maze is the State Health Insurance Assistance Program (SHIP). SHIP is funded by government grants and private donations; it has no connection to the health care or insurance industries. SHIP provides free counseling to seniors about Medicare managed care plans and Medigap. The 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.

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