Two Medicare Advantage Plans Look Similar. Compare the Care Network Before You Enroll

You have two Medicare Advantage plans on the screen. Both cover the benefits Medicare requires. Both may advertise additional benefits. That does not tell you whether your parent can keep the doctors, hospital, therapy provider, pharmacy, and equipment supplier already holding the care together.

Local option: New Plan Care gives families in the St. Louis area in-home help so a parent can stay home: companionship, help with bathing and dressing, meals, and overnight care. Call (314) 405-0887.

Your first comparison is not the premium. It is the path from a physician's order to a paid claim. Open a worksheet with one column for each plan. Do not enroll until you have filled the gaps with documents or calls to the plan.

Who pays

A Medicare Advantage plan becomes the payer for most Part A and Part B services. The plan must cover the medically necessary services Original Medicare covers, but it may use a provider network and require prior authorization for certain services or supplies. Most Medicare Advantage plans also include Part D drug coverage. Medicare explains these structural differences in its Original Medicare and Medicare Advantage comparison.

Write down the plan type before comparing anything else. An HMO generally requires network providers for nonemergency care and may require referrals. A PPO generally permits out-of-network care at a higher member cost. Other plan types use different access rules. Medicare's plan-type table shows the basic network and referral differences, but the individual plan's documents control the actual arrangement.

Make a provider list from records, not memory. Include the primary care physician, every specialist still involved, the preferred hospital system, outpatient therapy, behavioral health, home health, laboratory, imaging center, pharmacy, and any durable medical equipment supplier. Add the exact practice address because one office location can participate while another does not.

Search each name in the plan directory, then call both the provider and the plan. Ask the provider, "Are you in network for this exact plan name and contract, not merely with this insurance company?" Ask the plan the same question and request a call reference number. Medicare says you can obtain the directory from the plan and should confirm participation with the provider when scheduling, because networks can change. See Medicare's provider-network fact sheet.

Do not treat an additional benefit as interchangeable with covered medical care. For example, Medicare home health coverage has eligibility, ordering, and certified-agency requirements, and it does not pay for round-the-clock home care, meal delivery, unrelated homemaker work, or personal care when that is the only need. The physician or other authorized clinician decides what care is medically necessary. The plan tells you how its coverage and authorization rules apply. Start with Medicare's home health coverage page, then send unresolved payer questions to the plan.

The papers

Download the full Evidence of Coverage for each candidate. Do not compare only the marketing summary. Medicare describes the Evidence of Coverage as the document containing the plan's coverage and member-cost details.

Pull these items into one folder for each plan:

1. Evidence of Coverage.
2. Summary of Benefits.
3. Provider and pharmacy directories.
4. Part D formulary, including the covered tier and restrictions for every prescription.
5. Prior authorization list.
6. Referral rules.
7. Enrollment request and confirmation.
8. Any written answer or call reference number supplied by the plan.

Search the Evidence of Coverage for the services your parent actually uses. Record the member responsibility for primary care, specialists, hospital care, outpatient therapy, home health, ambulance service, emergency care, equipment, and out-of-network care. Record the medical deductible and the maximum out-of-pocket amount separately. Then call the member or sales number and ask whether the amount is a copayment per visit, coinsurance based on an allowed amount, or another calculation. Ask what spending counts toward the limit. Put the representative's name, answer, and reference number beside the question.

For prescriptions, enter the exact drug name, strength, quantity, and pharmacy into Medicare Plan Compare. Then check the formulary itself for prior authorization, step therapy, and quantity limits. Medicare explains these restrictions on its drug-plan rules page. A physician or prescriber decides whether an alternative medication is appropriate. Your job is to identify the restriction and place it in front of that clinician, not to substitute one drug for another.

If you need authority to handle a claim, grievance, coverage request, or appeal, read Form CMS-1696, Appointment of Representative. It authorizes the named representative to make requests, present evidence, receive information, and receive communications for the matter covered by the appointment. It is not a general financial power of attorney. If capacity, guardianship, or the validity of another legal document is disputed, stop and take the documents to a Missouri lawyer.

The runway

Run a paper test before submitting enrollment. Pick one likely month of care and trace each service through the proposed plan:

Physician order or referral - prior authorization, if required - in-network provider - service delivered - claim submitted - plan payment - member bill.

Circle every handoff you cannot verify. For each circle, call the plan and ask a closed question. "Does outpatient physical therapy require prior authorization under this plan?" is useful. "Is therapy covered?" is too broad. Ask how authorization is requested, who submits it, whether the provider must wait for approval, and where you can read the rule in the Evidence of Coverage.

Next, test disruption. Ask what happens if the primary care physician leaves the network, the usual hospital is out of network, the home health agency cannot accept the referral, or the equipment supplier changes. Ask whether continuity protections apply and how to request them. Do not assume a physician's presence in an online directory guarantees access at the location you need.

Keep employer, union, retiree, VA, TRICARE, and Medicaid coverage in a separate row on the worksheet. Medicare warns people with other benefits to speak with the benefits administrator, insurer, or plan before changing coverage. Enrollment in a Medicare Advantage plan can affect how other coverage works. Do not cancel existing coverage until the responsible payer or benefits administrator explains the consequence in writing or points you to the controlling plan document.

Your final sheet should show more than a projected total. It should show which plan has verified providers, which services require permission, which prescriptions carry restrictions, what happens outside the network, and who answers when the claim stops. If a cell is blank, you do not have an answer yet.

Free help

Missouri SHIP provides free, unbiased, confidential Medicare counseling and does not sell insurance. Take both plan names, the provider list, prescription list, Evidence of Coverage documents, and your unanswered questions to a counselor. Use the official Missouri SHIP page or begin with this desk's local help list.

You can also call Medicare at the number shown on Medicare's drug coverage page for general coverage and enrollment questions. Call the plan itself for its network status, authorization rules, and member-cost calculations. Ask for the exact document section and a reference number every time.

Sign the enrollment request only after the comparison sheet is complete, the other coverage has been checked, and the plan has answered every rate question that matters to your parent's likely care. The physician takes over when the question becomes what treatment or service is medically appropriate. A lawyer takes over when the question becomes whether someone has legal authority to act or whether a disputed document is valid.