Medicare Open Enrollment Guide: Navigating Plan Changes, Out-of-Network Providers, and Drug Cost Updates

Open Enrollment Period

The Medicare Advantage open enrollment period runs from January 1 to March 31. During this time, Medicare Advantage enrollees can switch plans or return to original Medicare. Transfers from traditional Medicare to Medicare Advantage are not permitted until the fall enrollment period.

Reasons to Consider a Plan Change

Medicare expert Philip Moeller recommends reviewing Medicare Advantage coverage annually due to changes in drug plans and reductions in routine dental, hearing, and vision care coverage. This review is particularly important if you're concerned about maintaining access to specific healthcare providers.

Out-of-Network Providers

Unlike original Medicare, Medicare Advantage plans have specific provider networks that can change regularly. If your preferred provider is no longer in your network, you may consider switching plans to ensure their continued care.

Drug Coverage Updates

Drug Cost Cap: The Inflation Reduction Act caps out-of-pocket prescription drug costs at $2,000 per year for beneficiaries with Part D plans.

Deductibles: Be aware that Advantage plans with deductibles have increased significantly in 2025 compared to 2024.

Prior Authorizations: New CMS rules require Medicare Advantage insurers to process prior authorization requests more efficiently, effective in 2026.

Traditional Medicare

Consider Supplemental Coverage: Traditional Medicare does not have built-in out-of-pocket cost caps, requiring supplemental insurance (Medigap) to cover additional expenses.

Medigap Guarantee: New enrollees have a guaranteed right to purchase Medigap coverage without pre-existing condition exclusions during the first Medicare Part B enrollment period.

Existing Conditions: Medigap plans in most states can deny coverage for pre-existing conditions after the first year of traditional Medicare or disenrollment from an Advantage plan.

Where to Get Help

* State Health Insurance Assistance Program (SHIP): Offers free one-on-one counseling in every state.
* Medicare Rights Center: Provides a free consumer helpline at 800-333-4114.
* Medicare: Contact directly at 800-633-4227.
* Medicare Plan Finder: Enter your medications to see coverage and compare plan costs.

Additional Tips

* Consider alternative medications if necessary to ensure coverage under your plan.
* Review Medicare Star Ratings for plan quality comparisons.
* Make coverage changes before the end of the March 31 open enrollment period to avoid delays in coverage.
* Research and compare plans thoroughly before making any decisions.