Are You in the Wrong Medicare Advantage Plan? What to Review Now

Many people choose Medicare Advantage plans without exploring their options or noticing what changes their plan may have made, according to research from KFF, a health policy nonprofit. But now that a new year has started, you may realize the plan you picked during Medicare’s fall open enrollment doesn’t work for you. Or maybe you stuck with your old plan and it changed this year. (That can happen, too.)

“It’s set up especially for people who begin the year enrolled in a Medicare Advantage plan and allows them to make certain changes,” says David Lipschutz, associate director of the Center for Medicare Advocacy.

Even if you haven’t had a chance to stress test your plan yet, do some research while you still have time to change your mind. Are there providers or specialists you want to see or hospitals you prefer? Make sure they’re in your network.

Check your medications, particularly if you’re on a newer drug that may be covered differently by different plans. How much do your prescriptions cost under your plan?

Then, think about your situation this year. “Are there any procedures, like a surgery that’s coming up?” says Christopher Fong, director and co-founder of Smile Insurance Group in Mesa, Arizona. “Is it outpatient? Inpatient? How many emergency room visits do you have? Do you need an electric scooter?” The more you can predict your health care usage, the more accurately you can determine whether you’re in the right plan.

Next, consider your lifestyle. Do you travel or plan to spend part of the year in another state? Make sure your insurance offers an extended network or travel benefit. Or consider Original Medicare, which allows you to see any doctor in the country who accepts Medicare.

During this time, people who are already enrolled in a Medicare Advantage plan can switch — once — to another Medicare Advantage plan, or they can return to Original Medicare and purchase a Medicare Part D prescription drug plan. But if you don’t already have Medicare Advantage, you can’t join a plan now.

That said, although you can return to Original Medicare, you may not be able to sign up for Medicare Supplement Insurance, or Medigap. Medigap’s open enrollment period — when insurance companies must offer you a plan at the same price as everyone else, regardless of health issues — lasts for six months after you’re 65 and have Medicare Part B. After that, aside from a few states and situations, you’ll be subject to medical underwriting to qualify.

“While you can get in and out of a Medicare Advantage plan on an annual basis, your rights to purchase a Medigap policy are usually far more restrictive,” Lipschutz says.

Some circumstances are red flags — meaning you should probably change your coverage. If your primary care physician or primary hospital system is now out of network, for instance, you’ll want to look for a plan that includes them.

If an expensive medication isn’t covered, see if there’s a plan that includes it. (You can input your medications into the plan finder on Medicare.gov to see options.) Make sure, when you’re estimating drug costs, that you’re as accurate as possible about what you’re taking, including name and dosage. “Some people will get confused between the generic version and the brand name version, and there’s a huge difference,” says Emily Gang, CEO of the Medicare Coach, a site that provides Medicare guidance.

If you had a health event and found that you weren’t covered in the way that you expected, give switching plans some thought, but consider that any money you’ve paid is a sunk cost. You’ve already spent it, Gang says. And it may not make sense to start over in a new plan with a new deductible.

In general, resist switching plans for the perks alone. “We’re not proponents of benefit chasing unless everything else lines up correctly for the member,’” Fong says.

Then, next year, do your homework during Medicare’s fall open enrollment from Oct. 15 to Dec. 7. “Ideally, you look at the plan details in advance to avoid any surprises,” Gang says.