Questions to Ask Before Changing Medicare Plans

Five Questions to Ask Before You Change Medicare Plans

If you are considering new coverage for next year, knowing the right questions to ask before changing Medicare plans can help you avoid costly surprises. This guide shows you how to verify your doctors, facilities and prescriptions, compare your financial exposure and protect future coverage options. Gather your current plan documents, provider list and medication details, then use these five questions for every plan you are considering.

Question 1: Are My Exact Doctors and Specialists Truly In-Network?

Do not ask only whether a doctor “takes Medicare.” Original Medicare generally lets you visit any provider nationwide who accepts Medicare, while Medicare Advantage plans use contracted networks. A practice may accept one plan from an insurance company but not another plan from the same company.

Check each doctor at the practice-address level. Ask the billing office to confirm the complete plan name and contract ID. If possible, provide the doctor’s National Provider Identifier, or NPI. Then confirm the result directly with the plan.

• Is my primary care doctor in-network at the location where I receive care?
• Are each of my specialists and their practice locations in-network?
• Will I need a referral before seeing a specialist?
• Does the plan cover out-of-network care, and what would I pay?
• What happens if one of my doctors leaves the network during the year?

Plan type matters. An HMO usually requires a primary care doctor and referrals for specialist care; except for emergencies, out-of-network services may not be covered. A PPO generally does not require specialist referrals and may cover out-of-network care at a higher cost. Our overview of Medicare Advantage HMO and PPO plans explains these structures.

Question 2: Are My Preferred Hospitals, Surgery Centers and Labs Included?

A doctor’s network status does not automatically extend to the hospital, ambulatory surgery center or laboratory that the doctor uses. This matters when a physician schedules a procedure at one facility but has privileges at several.

List the facilities you are likely to use, including your preferred hospital, urgent care center, imaging location, ambulatory surgery center and diagnostic laboratory. Confirm each location against the exact plan, not simply the carrier’s name.

• Where would my doctor admit me for planned hospital care?
• Which facility would perform a colonoscopy, cataract surgery or other outpatient procedure?
• Which laboratory will process blood or tissue samples?
• Are both the facility and the professionals working there in-network?
• What are my costs if a sample is sent to an out-of-network laboratory?

Depending on the plan and service, an out-of-network laboratory may lead to 20% to 40% coinsurance or no coverage under a closed network. Ask where specimens are processed before routine testing. Our guide to spotting Medicare Advantage coverage gaps covers other network and cost issues.

Question 3: How Does the Formulary Treat My Prescriptions and Pharmacy?

Prescription coverage must be checked separately from medical coverage. A drug may be covered by one plan but excluded, placed on a higher tier or restricted by another. Pricing can also differ among pharmacies in the same plan.

Create a medication list with each drug’s exact name, dosage, form and frequency. Search each version in the plan’s formulary and confirm its tier. Many formularies use five tiers, progressing from lower-cost preferred generics to specialty medications.

• Is my exact drug, strength and form on the formulary?
• What will I pay at my current pharmacy for a 30-day and 90-day supply?
• Is my pharmacy preferred or merely in-network?
• Would mail order reduce the cost?
• Does the medication require prior authorization, step therapy or a quantity limit?
• If coverage is denied, what is the exception or appeal process?

A preferred cost-sharing pharmacy may charge less than another in-network pharmacy. Medicare’s Part D plan rules explain that quantity limits restrict how much medication is covered at one time, while step therapy may require you to try a lower-cost drug first.

Review the upcoming year’s formulary and pharmacy network rather than assuming your current coverage will continue, especially if you take maintenance or specialty medications.

Question 4: What Is My Real Financial Exposure?

A low or $0 plan premium does not show the full cost of coverage. Compare what you could pay during a year with regular appointments, testing or hospital care. Include the Part B premium, any plan premium, deductibles, copayments and coinsurance.

Pay particular attention to the medical maximum out-of-pocket limit, or MOOP. For 2026, KFF reports that Medicare Advantage plans cannot exceed $9,250 for in-network services or $13,900 for combined in-network and out-of-network services, although a plan may set lower limits.

• What is the in-network medical MOOP?
• Does a PPO have a separate combined in-network and out-of-network limit?
• What are the costs for specialists, diagnostic imaging, outpatient surgery and hospital stays?
• Is a service charged as a fixed copayment or a percentage of the allowed cost?
• How much would I spend under a realistic high-use scenario?

Medical and prescription spending are tracked separately. In 2026, the Part D out-of-pocket cap is $2,100, and drug expenses do not count toward the Medicare Advantage medical MOOP. Compare both limits rather than treating them as one protection.

Question 5: How Will Switching Affect My Long-Term Coverage Rights?

Before leaving a plan, check whether you can obtain the replacement coverage you want. Enrollment periods permit certain changes, but they do not always create a guaranteed right to buy a Medicare Supplement policy.

According to Medicare Interactive, the Annual Enrollment Period runs from October 15 through December 7, while the Medicare Advantage Open Enrollment Period runs from January 1 through March 31 and applies only to people already enrolled in Medicare Advantage. Annual Enrollment Period changes take effect January 1; during Medicare Advantage Open Enrollment, you may change Medicare Advantage plans or return to Original Medicare.

Moving from Medicare Advantage to Original Medicare does not automatically guarantee acceptance into Medigap. Federal trial rights may protect you in specific situations, including certain changes made within your first 12 months in Medicare Advantage. Outside a guaranteed-issue right, insurers in many states may use medical underwriting.

• Do I have a Medigap open-enrollment, trial or guaranteed-issue right?
• Should I confirm Medigap acceptance before leaving Medicare Advantage?
• Will I need a separate Part D prescription plan?
• Could my change create a gap in drug coverage?
• When will the new coverage take effect?

Standardized Medigap policies are guaranteed renewable once issued. The insurer cannot cancel the policy because your health changes as long as you pay the premium. If broader provider access is your priority, review how Original Medicare and Medicare Supplements work before changing coverage.

Get a Thorough Medicare Review Before You Commit

Route 66 Health Insurance & Beyond is a veteran-owned agency established in 2013. We provide free consultations and quotes to help Medicare-eligible individuals compare plan networks, providers, prescription coverage and potential costs across 26 states.

Bring your doctors’ names and practice addresses, preferred facilities and complete medication list. Request a free Medicare consultation, call Route 66 Health Insurance & Beyond at (312) 420-3396 or email jevans@myrt66ins.com. We are based in Plainfield, IL.