When reviewing your options during Medicare open enrollment, monthly premiums and prescription drug costs matter. But there’s another important question to ask: Will this plan give you access to the doctors, hospitals and care you want?
If you have questions about your health or ongoing medical needs, schedule an appointment with a Mercy Health primary care provider.
Choosing a Medicare plan
Medicare open enrollment runs from Oct. 15 through Dec. 7, and changes made during this period generally take effect Jan. 1. During open enrollment, people with Medicare can change Medicare Advantage or drug plans or switch between original Medicare and Medicare Advantage.
Before making a decision, take time to compare your options and consider your current health needs as well as care you might need in the future.
Look beyond the monthly premium
Costs are important, but Emmett Roper, MD, a Mercy Health primary care physician in our Cincinnati market, encourages patients to consider access to care, too.
“In my experience, some of the most difficult conversations happen when a patient needs care and learns that insurance requirements may affect where, when or how that care is delivered.”
Original Medicare generally allows you to see any doctor or hospital in the U.S. that accepts Medicare. Medicare Advantage plans may require you to use providers within the plan’s network for non-emergency care and may require referrals for specialists.
That makes it important to check whether your primary care provider, specialists, preferred hospital and other health care facilities are in network before choosing a Medicare Advantage plan. Medicare also recommends checking provider participation each year during open enrollment.
Understand prior authorization
Some Medicare Advantage plans require prior authorization, meaning the plan must approve certain health care services before they are covered.
For medical services subject to current federal prior authorization requirements, Medicare Advantage organizations generally must respond to standard requests within seven calendar days and expedited requests within 72 hours, although certain extensions can apply.
“A postponed scan can delay a diagnosis. A delayed treatment can prolong suffering. A delayed rehabilitation stay can slow recovery,” Dr. Roper explains.
Before enrolling, ask which services require prior authorization and what happens if authorization is denied, including how to appeal the decision. Medicare Advantage beneficiaries have appeal rights when they disagree with coverage decisions.
Questions to ask when comparing Medicare plans
Before selecting coverage, consider asking:
- Are my doctors, specialists and preferred hospitals in network?
- Are my medications covered, and are my preferred pharmacies in network?
- Which services require referrals or prior authorization?
- What happens if coverage for a service is denied?
- What will I pay for specialist visits, hospital stays and other services?
- Is there coverage for nonemergency care when I’m outside the plan’s network?
- Are dental, vision or other supplemental benefits useful for my needs?
- Could my overall costs be higher even if the plan has a low or $0 premium?
You can also use Medicare’s Plan Compare tool to compare available Medicare health and drug plans.
How we can help
Choosing Medicare coverage is a personal decision. Your doctors, medications, health needs, budget and preferred hospitals can all influence which option works best for you.
“The right choice depends on a person’s doctors, medications, health care needs, budget and preferences,” Dr. Roper says.
Before selecting a plan, verify that the doctors and facilities you want to use participate in that plan. Mercy Health recommends confirming coverage and restrictions directly with your insurer because participation and plan requirements can change. Review insurance plans accepted by Mercy Health, and find a Mercy Health provider to help manage your health care needs.
Learn about the primary care services we offer at Mercy Health.
