You have two Medicare Advantage plans on the screen. Both list hospital coverage, doctor visits, prescriptions, and extra benefits. That is not enough to choose. Your working comparison is the care your parent is likely to use: the physicians, hospital system, pharmacy, medicines, equipment supplier, therapy clinic, and recurring services already in the household file.

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.

Who pays

A Medicare Advantage plan receives payment from Medicare and administers Medicare-covered services under its own network, cost-sharing, referral, and prior-authorization rules. Your parent must keep Medicare Part B and may owe the plan premium in addition to the Part B premium. Plan terms can differ even when the benefit headings look alike. Start with the payer overview in Who Pays for Care at Home in St. Louis, then compare the plans as contracts rather than advertisements.

For each plan, call the member or prospective-member number and ask for the current premium, medical deductible, drug deductible, copayments, coinsurance, and medical out-of-pocket maximum. Ask whether out-of-network spending counts toward that maximum. Read the representative each service you expect to use. Do not turn a maximum into a forecast. It is a limit defined by the plan, not a promise that the household will spend that amount.

Build the provider test

Make one row for every physician, hospital, laboratory, pharmacy, equipment supplier, home health agency, and therapy provider your parent uses. Search the plan directory, but do not stop there. Call the provider and ask whether the specific clinician or location participates in the exact plan name and plan type. Then call the plan and ask the same question. Record both answers, the numbers called, the representative names, and any confirmation number.

Ask a second question: “Is this provider accepting patients under this plan?” A directory entry does not tell you whether an office will schedule a new patient. If the plan says a provider is in network and the provider says otherwise, leave the row unresolved. Ask the plan how it will confirm participation in writing before enrollment.

For an HMO, identify the primary care physician, referral rules, and exceptions for urgent care, emergencies, and out-of-area dialysis. For a PPO, write down both the in-network and out-of-network cost for each likely service. Out-of-network access is not useful if the provider will not accept the plan or the household cannot carry the higher cost.

The papers

Collect the Summary of Benefits, Evidence of Coverage, provider directory, pharmacy directory, and formulary for each exact plan. If your parent already has a plan, add its Annual Notice of Change. These documents serve different jobs: the summary is a short comparison, while the Evidence of Coverage contains the operating rules and fuller cost terms. The plan documents and official public sources behind this checklist are identified on the site’s Sources page.

Search each Evidence of Coverage for “prior authorization,” “referral,” “out of network,” “maximum out-of-pocket,” “inpatient hospital,” “skilled nursing,” “home health,” “durable medical equipment,” “ambulance,” and “appeal.” Put the page number beside every answer in your spreadsheet. If a sales page conflicts with the Evidence of Coverage, stop and ask the plan which document controls.

For prescriptions, use the exact drug name, dose, form, and quantity. Record the formulary tier, prior authorization, step therapy, quantity limit, deductible treatment, and cost at the pharmacy your parent actually uses. Ask whether that pharmacy has preferred or standard cost sharing. Send any question about changing a medicine to the prescriber. Your job here is to compare coverage rules, not to substitute one drug for another.

Test the approval route

List services your parent receives repeatedly or may need to continue without a gap. Ask each plan whether the service requires prior authorization, who submits the request, how long an approval remains valid, and whether a new authorization is required after enrollment. Ask what happens to an authorization already issued by another insurer.

If an upcoming service is important to the choice, ask whether the plan can issue an organization determination stating whether it will cover the service and what your parent will owe. Get the request instructions from the plan. If the answer depends on medical necessity, diagnosis, or clinical records, stop at the physician’s office and ask the treating clinician to handle that part.

The runway

Do not compare only the premium. Build three columns for each plan: routine use, one plausible high-use period, and the medical out-of-pocket maximum. Include premiums, deductibles, office and specialist visits, hospital cost sharing, recurring therapy, equipment, and expected prescriptions. Use the plan’s quoted amounts, mark every unknown, and call the plan rather than inserting a local average or online estimate.

Then test continuity. Write the effective date, the last day of the current coverage, the first refill after the change, and every appointment or scheduled service near the handoff. Confirm when identification cards arrive, how prescriptions are handled before the card arrives, and where the plan sends authorization requests. Do not cancel existing coverage merely because an application was submitted. Confirm enrollment and the effective date first.

Free help

Missouri SHIP provides free, unbiased Medicare counseling and does not sell plans. Bring both plan names, the medication list, provider list, and your unresolved questions. Ask the counselor to help you check the Medicare plan comparison results against the Evidence of Coverage and network answers. Contact routes are collected at Local Help With Paying for Care.

Your stopping rule is simple. Do not sign while a required physician, hospital, medicine, or recurring service is marked “probably covered.” Turn each one into a documented yes, a documented no, or a known risk the household has deliberately accepted. If you need the larger reading order before making the payer choice, use Start Here: The Order to Read.

Two Medicare Advantage Plans Look Alike. Make the Network, Approval Rules, and Full Cost Prove the Choice