7 Questions to Ask Before Choosing a Medicare Plan

Choosing a Medicare plan can feel overwhelming. Between Medicare Advantage, Medicare Supplement, and Part D options, the number of plans available in most areas runs into the dozens. But you do not need to understand every plan. You need to understand your own situation and ask the right questions.

Here are 7 questions I walk through with every client before recommending a plan. These questions cut through the noise and get to what actually matters for your coverage and your budget.

1. Are my current doctors in the plan's network?

If you are considering a Medicare Advantage plan, this is the most critical question. Medicare Advantage plans use networks of doctors and hospitals. Seeing an out-of-network provider can cost significantly more, and some plan types (like HMOs) may not cover out-of-network care at all except in emergencies.

If staying with your current doctors is a priority, verify that each one is in the plan's network before you enroll. If you prefer the freedom to see any doctor, a Medicare Supplement plan with Original Medicare may be a better fit, since any doctor who accepts Medicare will accept you.

2. How much will my prescriptions cost under this plan?

This is where the real cost comparison happens. Every Part D plan and Medicare Advantage plan with drug coverage uses a formulary. The same medication can be on a low-cost tier with one plan and a high-cost tier with another. I run a drug cost comparison for each client that calculates the total annual cost of their medications under every available plan. The differences between the cheapest and most expensive options can be hundreds of dollars per year.

3. What is the plan's maximum out-of-pocket limit?

Medicare Advantage plans have a maximum out-of-pocket (MOOP) limit, which caps what you pay in a year for covered services. Once you hit this limit, the plan pays 100% for covered services for the rest of the year. This cap provides protection against catastrophic costs.

Original Medicare with a Medigap plan works differently. Depending on which Medigap plan you choose, your out-of-pocket costs may be minimal regardless of how much care you receive. Plan G, for example, covers nearly all out-of-pocket costs after the Part B deductible.

Ask yourself: how important is cost predictability to you? If you want to know exactly what you will spend each month, a Medigap plan may provide more peace of mind. If you are comfortable with variable costs and want a lower monthly premium, Medicare Advantage may work well.

4. Does this plan cover the services I need most?

Beyond basic medical coverage, consider what specific services matter to you:

• Do you need regular lab work or imaging?
• Do you see a mental health professional?
• Do you need physical therapy or rehabilitation?
• Is dental, vision, or hearing coverage important to you?
• Do you need durable medical equipment?

Medicare Advantage plans often include extra benefits like dental, vision, and hearing at no additional cost. Original Medicare does not cover these services in most cases, so you would need to purchase separate coverage if these are important to you.

5. What happens if I travel or spend time in another state?

If you travel frequently, split your time between two locations, or plan to spend extended time away from your home area, this question matters. Medicare Advantage networks are typically regional. If you are in another state, you may only be covered for emergency or urgent care.

Original Medicare with a Medigap plan works nationwide. Any doctor who accepts Medicare in any state will accept you. For people who travel regularly, this flexibility can be a deciding factor.

6. How much is the total annual cost, not just the premium?

The monthly premium is only one part of the picture. A plan with a $0 premium may have higher copays, deductibles, and coinsurance that add up to more than a plan with a moderate premium. I calculate the total estimated annual cost for each client based on their actual healthcare usage, including premiums, deductibles, copays, and drug costs. This total cost comparison is the only way to make an apples-to-apples decision.

7. What is the plan's star rating?

Medicare evaluates plans every year using a 5-star rating system. Plans are rated on factors like quality of care, customer service, and member satisfaction. A 5-star plan has demonstrated consistently high quality. While the star rating is not the only factor, it is a useful indicator of how well a plan performs for its members.

Plans with 5-star ratings also offer a special enrollment benefit: you can switch to a 5-star plan at any time of year, not just during the Annual Enrollment Period.

The right plan is the one that matches your doctors, covers your medications at the lowest cost, and gives you the level of flexibility and predictability you need. These 7 questions help you find that plan.