MA and PDP Selection Process

Once you determine eligibility, when educating clients on how to choose a MA and a PDP, you should follow the steps recommended by CMS in the Medicare & You handbook most current edition. Also called need assessment process, this is a simple but very effective process to follow; it will open up the conversation and will help you determine if there is a need from your client.

1. Cost.
What will you pay out-of-pocket for premiums, coinsurance, copayments, and deductibles?

2. Benefits
When choosing between the Original Medicare Plan and a Medicare Advantage Plan (like an HMO or PPO), are extra benefits like eye exams or hearing aids covered? How does what you pay for hospital stays and other costs differ?

3. Doctor and hospital choice
Does your doctor(s) accept the plan? Can you see the doctor(s) you want? Are they accepting new patients? Do you have to choose your health care providers from the plan’s network? Do you need a referral to see a specialist? Can you go to the hospital you want, or do you have to go to a network hospital? Do you pay less to go to certain doctors or hospitals?

4. Convenience
Where are the doctors’ offices? What are their hours?

5. Travel
Do you spend part of each year in another state? Will the plan cover you there?

6. Prescription drugs
What will your prescription drugs cost under the plan’s formulary? What are your drug needs?

7. Pharmacy choice
What pharmacies can you use?

Having this information will assist you to provide a well informed recommendation to your client. It is important to keep records of this appointment for future reference.