8 Points to Consider When Choosing a Medicare Managed Care Plan

Medicare doesn't come in only one flavor. There's traditional Medicare Part A and Part B , supplemented by a medigap private insurance policy . But there are also Medicare Part C managed care plans , called Medicare Advantage, which blend the other types of coverage into one. If your parent considers enrolling in a Medicare Advantage plan as an alternative to traditional Medicare plus a medigap policy, make sure to check the following things first:

Are all the doctors my parent usually sees in the managed care plan's network?

The basic rule of Medicare managed care is that a plan will pay its full share only for care received from a doctor in the plan's network, a roster of doctors who are under contract with the plan. Many plans pay nothing at all if your parent receives care from a doctor outside the network; others pay only a small portion of the bill. If all of your parent's doctors are listed on a plan's network, that plan becomes a good candidate. If some of your parent's regular doctors are not on the network and she wants to stay with them, then look for another plan, or opt for traditional Medicare plus medigap, which covers virtually all doctors. On request, a Medicare Advantage plan will provide you with its current network list, which is usually also on its website.

Does the plan's network include a wide selection of nearby specialists?

Your parent should consider not only whether her current doctors are on the network list but also whether the network includes a wide selection of specialists near where she lives. This is especially important in rural and suburban areas where the number of specialists may be limited. Although your parent may not need any of these doctors right now, the reality of aging is that specialists are likely to come into the picture sooner or later.

Is the hospital where my parent would be admitted in the plan's network?

Not every hospital is in every Medicare Advantage plan network. If your parent's doctors refer their patients only to a particular hospital, or if your parent's home is near only one good hospital, make sure that hospital is in a plan's network before signing up with that plan.

What are the plan's total costs -- premiums plus deductibles and copayments?

A Medicare Advantage plan may have a very low monthly premium, or even no premium at all. But that doesn't tell you what the actual cost of the plan would be for your parent. Before enrolling in a plan, make sure she knows whether she must pay the monthly Medicare Part B premium; what the plan's own premium is; and what the plan's copayments and deductibles are for inpatient hospital or nursing-facility stays, doctor visits, outpatient hospital visits (including the emergency room), X-rays, laboratory work, and physical and occupational therapy.

What to Ask About Medicare Advantage Care Plans

Does the plan pay any amount for care from providers outside the network?

Some Medicare Advantage plans pay a portion of medical bills for service from a doctor or other provider who's not in the plan's network. Other plans p ay nothing at all for care from outside the network. If a plan is otherwise attractive but its network doesn't have an extensive roster near where your parent lives, then its rules regarding payment for care outside the network might be an important factor in choosing whether or not to enroll.

What services does the plan cover that Medicare doesn't?

One of the attractive features of most Medicare Advantage plans is their coverage of medical care not covered by traditional Medicare . A plan that offers extra services that your parent regularly needs -- such as eye exams and glasses, hearing tests and aids, chiropractic, or dental care -- may make that plan more attractive than a plan without such extras.

What does the plan cover when my parent is away from home?

Does your parent regularly spend time away from home, either traveling, staying at a second home, or visiting you or other family members? All Medicare Advantage plans must cover emergency and urgent care while your parent is anywhere in the United States. But there is no requirement that nonurgent care be covered, nor is there any required coverage outside the country. So, if your parent is often away, it's important to learn what coverage a Medicare Advantage plan would offer.

How does the plan compare to available medigap policies?

If your parent is considering a Medicare Advantage plan, it's a good idea to compare it not just with other Part C managed care plans but also with medigap supplemental insurance policies available where your parent lives. Medigap policies coordinate with and supplement traditional Medicare, filling in many of the gaps left unpaid by Parts A and B. Some medigap policies also cover certain extras also offered by Medicare Advantage plans (see "What services does the plan cover that Medicare does not?" above). So, before choosing a Medicare Advantage plan, compare it side by side with traditional Medicare Parts A and B combined with each good available medigap plan; be sure to look at premiums, deductibles, and copayments, as well as coverage away from home and extra services not covered by Medicare itself.

Joseph L. Matthews

Joseph Matthews is an attorney and the author of numerous books, including Social Security, Medicare, and Government Pensions, Long-Term Care: How to Plan and Pay for It; How to Win Your Personal Injury Claim; and The Lawyer Who Blew up His Desk. See full bio