Making Healthcare Insurance Decisions

With the open enrollment period for Medicare coming soon, my wife and I will soon be inundated with advertisements and promotional material for our coverage. We are both current Medicare enrollees. She is in the traditional Medicare program (Parts A and B), with added coverage for the Medicare Part D drug program and a supplemental policy. I participate in a Medicare Advantage Program (Part C), which includes the hospitalization and physician services of the traditional Medicare program as well as the drug coverage of Part D. My total premiums are substantially less than hers.

So, why did I choose to have the separate types of coverage for her? It basically comes down to our respective health profiles. Unfortunately, my wife has a long and complicated health history, with multiple hospitalizations and surgeries. In contrast, I have been relatively healthy for most of my life.

By choosing traditional Medicare for her, we are able to access a broader network of doctors and hospitals. We can seek coverage from any provider who accepts Medicare as insurance. Medicare Advantage, on the other hand, functions more like an HMO. I select a primary care physician, and must seek referral approval before seeing any specialist. I am also limited in the physicians and hospitals that I can use for full coverage. Before selecting my Advantage coverage, I reviewed the list of providers and found almost all of my normal providers were covered, including my established primary care physician and cardiologist. Given my health history, I felt comfortable giving up some flexibility in order to reduce my premium cost.

For the most part, this strategy has worked out extremely well for both of us. My wife has felt comfortable, knowing that she would be able to seek care from the most appropriate provider for her conditions, and I have continued to be a low user of health services, with my only doctor visits being for routine or preventative care. The only wrinkle has been when my insurer provider narrowed its network as of September 1, and dropped a number of dermatologists, including the one that I have been seeing for 20 years. I was able to schedule my annual visit prior to the drop date, but am now faced with the decision of changing doctors or changing plans during open enrollment.

Which I guess brings me to the point of this whole article. We have abundant choices in selecting our insurance coverage, especially if you are covered by Medicare, but even those with employer-sponsored coverage often have the choice of trading off broader coverage for a change in their premium.

Here are some of the factors that I think you could use in making your choices:

  • How healthy are you? Your covered family members? Does anyone have any chronic health conditions that require specialized care?
  • Do you have an established network of healthcare providers that you want to continue to use?
  • What are your prescription drug requirements?
  • How much flexibility do you want in adding new healthcare providers?
  • How much can you afford/are willing to pay?

Using the tools that are available on the internet, you can make informed decisions on these choices yourself, or you can use the services of health care navigators or consultants to help you with the process.

It can seem confusing, especially if you are dealing with a complicated situation, but the good news is, in most instances, your choices are only good for one year, and you will have the chance to make a change if your needs are not being met.