Have you felt satisfied with your Medicare plan this year? Or do you feel that your coverage is lacking, or your out-of-pocket costs are too high? You do have the option to switch plans if you’re not happy with your current one. Each year, Medicare operates an Annual Election Period from October 15 to December 7, during which you can drop your current plan and choose a new one. Here’s what you need to know.

Anyone can change their plan. Whether you’re enrolled in Original Medicare or a Medicare Advantage plan, you can make any of these changes during the Annual Election Period:

• Drop your Medicare Advantage plan and return to Original Medicare
• Switch from Original Medicare to a Medicare Advantage plan
• Change from one Advantage plan to another
• Choose a different Part D plan
• Enroll in Part D, if you haven’t before

Pay attention to certain variables within different plans. There’s no single plan that works best for everyone, and that’s why Medicare makes so many different options available. But in general, you should pay close attention to:

• Out-of-pocket costs such as premiums, copayments, and deductibles
• Coverage area, and facilities or doctors that are included in the plan’s network (for Medicare Advantage plans)
• The plan’s formulary, or list of covered prescription drugs (for Medicare Advantage and Part D plans)
• The latest news on Medicare regulations, such as caps on the cost of prescriptions and covered products like insulin

It’s not your last chance. If you choose a new plan and then change your mind about it during the Annual Election Period window, you can still change to a different plan before December 7. If you enroll in a Medicare Advantage plan and decide it’s not right for you, the Medicare Open Enrollment window from January 1 to March 31 will allow you to switch to a different Advantage plan, or return to Original Medicare if you prefer.

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There are many important choices to make about your healthcare coverage, and being informed can help you make the best decisions for your own needs.

People with Medicare can get their health coverage through either Original Medicare or a Medicare Advantage Plan (also known as a Medicare private health plan or Part C). While there are many differences between the two, remember that Medicare Advantage Plans must provide the same benefits offered by Original Medicare, but may apply different rules, costs, and restrictions.

Let’s review some of the main differences between these two ways to get your Medicare:

Costs

• Original Medicare: You will be charged for standardized Part A and Part B costs, including a monthly Part B premium. You are responsible for paying a 20% coinsurance for Medicare-covered services if you see a participating provider after meeting your deductible.
• Medicare Advantage: Your cost-sharing varies depending on the plan. You usually pay a copayment for in-network care. Plans may charge a monthly premium in addition to the Part B premium.

Supplemental Insurance

• Original Medicare: You have the choice to pay an additional premium for a Medigap policy to cover Medicare cost-sharing.
• Medicare Advantage: You cannot purchase a Medigap policy.

Provider access

• Original Medicare: You can see any provider and use any facility that accepts Medicare (participating and non-participating).
• Medicare Advantage: You can typically only see in-network providers.

Referrals

• Original Medicare: You do not need referrals for specialists.
• Medicare Advantage: You typically need referrals for specialists.

Drug coverage

• Medicare Advantage: In most cases, the plan provides prescription drug coverage (you may be required to pay a higher premium).
• Original Medicare: You must sign up for a stand-alone Part D plan if you want prescription drug coverage.

Other benefits

• Original Medicare: Does not cover vision, hearing, or dental services.
• Medicare Advantage: May cover additional services, including vision, hearing, and/or dental (additional benefits may increase your premium and/or other out-of-pocket costs).

Out-of-pocket limit

• Original Medicare: No out-of-pocket limit.
• Medicare Advantage: Annual out-of-pocket limit. Plan pays the full cost of your care after you reach the limit.

 Between the two options, one is not better than the other for everyone. Medicare Advantage and Original Medicare are just different, and you may prefer one over the other depending on your needs and priorities.

 Because you have a Medigap, I do want you to note that if you switch from Original Medicare to Medicare Advantage, you will lose your Medigap. Depending on your state’s Medigap enrollment rules, it may be difficult or expensive to purchase a Medigap later. There are only a few specific protected times to purchase a Medigap under federal rules, but your state may offer additional rights.

 To receive individualized counseling on your options, I recommend calling your local State Health Insurance Assistance Program (SHIP).

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Your health is important and needs to be protected. If you are 65 or older or have certain disabilities, or End-Stage Renal Disease, you can get health care coverage through the Medicare program. You’ll get access to health care services you need to achieve and maintain good health.

It’s important to review your Medicare coverage options and find an affordable option that meets your healthcare needs.

Medicare coverage options

There are two types of Medicare coverage:

• Traditional or Original Medicare.
• Medicare Advantage.

Original Medicare helps cover inpatient care in hospitals, skilled nursing facility care, hospice care, and home health care. It also covers:

• Services from doctors and other health care providers.
• Outpatient care.
• Durable medical equipment (like wheelchairs, walkers, hospital beds, and other equipment).
• Preventive services (like screenings, certain vaccines, and annual wellness visits).

Original Medicare is often referred to as Part A and Part B. You can go to any doctor or hospital, anywhere in the United States, that accepts Medicare. If you have Original Medicare, you can also buy a Medicare Supplement Insurance (Medigap) policy from a private insurance company. Original Medicare pays for much, but not all, of the cost for covered health care services and supplies. A Medigap policy can help pay some of the remaining health care costs, such as copayments, coinsurance, and deductibles.

Medicare Advantage bundles your Original Medicare – and usually Medicare prescription drug coverage – into one health insurance plan. If you select Medicare Advantage coverage, you join a plan offered by Medicare-approved private companies.

Each plan can have different rules for how you get services – like referrals to see a specialist. All plans must cover emergency and urgent care, as well as all medically necessary services covered by Original Medicare.

In many cases, you can only use doctors and other providers who are in your plan’s network and service area. Costs for monthly premiums and services vary depending on which plan you join. Some plans may offer some extra benefits that Original Medicare doesn’t cover — like vision, hearing, and dental services.

Whether you choose Original Medicare or Medicare Advantage, be sure you have prescription drug coverage. You can join a Medicare Prescription Drug Plan (called a PDP) in addition to Original Medicare. You can also get it by joining a Medicare Advantage plan with Medicare prescription drug coverage.

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All Medicare Advantage Plans must set an annual limit on your out-of-pocket costs, known as the maximum out-of-pocket (MOOP). This limit is high but it may protect you from excessive costs if you need a lot of care or expensive treatments. After reaching your MOOP, you will not owe cost-sharing for Part A or Part B covered services for the remainder of the year. Some plans may also apply the MOOP to supplemental benefits, such as vision, hearing, or dental.

The out-of-pocket costs that help you reach your MOOP include all cost-sharing (deductibles, coinsurance, and copayments) for Part A and Part B covered services that you receive from in-network providers. Part D cost-sharing does not count toward your plan’s MOOP.

In 2023, the MOOP for Medicare Advantage Plans is $8,300, but plans may set lower limits. If you are in a plan that covers services you receive from out-of-network providers, such as a PPO, your plan will set two annual limits on your out-of-pocket costs. One limit is for in-network costs and the other is for combined in-network and out-of-network costs.

Call your plan directly if you have questions about your annual out-of-pocket limit.

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Once you turn 65, it’s time to enroll in Medicare. But did you know that if you miss your original enrollment window, you can be subject to a penalty for late enrollment? It depends on the situation, but you could end up with higher premiums for life.

First, let’s review the typical course of action. At age 65, you become eligible for Medicare Parts A and B, or you can choose a Medicare Advantage plan which rolls both parts together. Medicare Part A covers hospitalization, and most of us qualify for free coverage due to our work history. But Part B charges a premium each month (or you pay Medicare Advantage premiums). If you don’t enroll during your original enrollment window at age 65, you will face a 10 percent higher premium for each year that you waited. That could add up to a significantly higher premium.

However, there is one exception to this rule. If you’re covered by an employer’s group healthcare plan, and that employer has more than 20 employees, then you can stick with the employer-provided plan until you leave that employment situation in the future. The same is true if you’re married and covered by your spouse’s employer-provided plan. In either of these situations, you can delay your Medicare enrollment until you retire or otherwise leave that company, and then enroll in Medicare without a penalty. Then you will have an 8-month Special Enrollment window in which you can choose a Medicare plan.

The only other situation in which you wouldn’t pay a penalty would be if you qualify for the Medicare Savings Program. This program is designed for very low-income people who cannot afford their Medicare premiums. If you qualify, you will also qualify for the Extra Help program which offers you a Part D (prescription) plan.

Since the penalties for late enrollment can add up, it’s very important not to miss your original enrollment window. But remember, you’re entitled to free help.

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Preventive care is the care you receive to prevent illness, detect medical conditions, and keep you healthy. Medicare Part B covers many preventive services, such as screenings, vaccines, and counseling. If you meet the eligibility requirements and guidelines for a preventive service, you must be allowed to receive the service. This is true for Original Medicare and Medicare Advantage Plans. However, your plan’s coverage rules may apply.

Original Medicare: You pay nothing (no deductible or coinsurance) for most preventive services when you see a participating provider.

Preventive services recommended by the U.S. Preventive Services Task Force are covered at 100% of the Medicare-approved amount (zero cost-sharing), but for other services, you may be charged Original Medicare cost-sharing.

• You may be charged if you see a non-participating or opt-out provider.
• Medicare Advantage: When seeing an in-network provider, you pay nothing for preventive services that are covered with zero cost-sharing by Original Medicare. This means that plans are required to cover your care without charging deductibles, copayments, or coinsurance, as long as you meet Medicare’s eligibility requirements for the service.
• Medicare Advantage Plans may charge you for preventive services that Original Medicare does not cover with zero cost-sharing.
• You may be charged if you see an out-of-network provider.

Under certain circumstances, you may be charged for services you receive related to your preventive service, even if the preventive service itself is covered at 100% of the cost. For example:

• During the course of your preventive care, your provider may discover and need to investigate or treat a new or existing problem. This additional care is considered diagnostic, meaning your provider is treating you because of certain symptoms or risk factors. Medicare may bill you for any diagnostic care you receive during a preventive visit. For example, if your doctor finds and removes a polyp during a colonoscopy, costs related to removing the polyp will apply.
• You may have to pay a facility fee depending on where you receive your preventive care. For example, certain hospitals charge separate facility fees when you receive a preventive service.
• You may be charged for a doctor’s visit if you meet with a doctor before or after receiving your preventive care.

Keep in mind that each preventive service has its own eligibility requirements and guidelines. Medicare may only cover a service a certain amount of times each year or under specific circumstances.

Note: Medicare may cover certain preventive services more frequently than guidelines suggest if they are needed to diagnose or treat an illness or condition.

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An Explanation of Benefits (EOB) is the notice that your Medicare Advantage Plan or Part D prescription drug plan typically sends you after you receive medical services or items. You only receive an EOB if you have Medicare Advantage or Part D. An EOB is not the same as a Medicare Summary Notice. It is also important to remember that an EOB is not a bill.

EOBs are usually mailed once per month. Some plans give you the option of accessing your EOB online. Your EOB is a summary of the services and items you have received and how much you may owe for them. It tells you how much your provider billed, the approved amount your plan will pay, and how much you have to pay to the provider.

While all EOBs provide the same information, the layout and other specifics may vary by plan. If your EOB shows that an item or service is not being covered, look for a section that includes notes, comments, footnotes, or remarks to find out the reason why. You may have to look on the next page to find this information.

Contact your plan if you have any questions about your EOB. You should also contact your plan for more information if any of your services or items were not covered. You may decide to file an appeal, depending on what your plan tells you.

Try to save your EOBs. You might need them in the future to prove that certain costs have been covered/paid for. For instance, you may need old EOBs if a provider’s billing department makes a mistake or if you claimed a medical deduction on your taxes.

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It is usually best if someone enrolls in Medicare when they are first eligible. As you mentioned, many people who delay enrolling in Medicare must wait for the General Enrollment Period and then may owe a late enrollment penalty for life.

Beginning this year, though, if someone misses a first-time enrollment period, there are certain situations when they might qualify for exceptional circumstances Special Enrollment Period (SEP).  One of these new SEPs is for people who were released from the custody of a penal authority, including a prison, after January 1, 2023.

To be eligible for this SEP, he would have to:

• Be eligible for Medicare
• Have failed to enroll in Medicare while he was incarcerated
• Be released on or after January 1, 2023

Note that Medicare defines “incarcerated” as individuals who are in the custody of certain authorities, including people under arrest, imprisoned, residing in halfway houses, living under home detention, or confined completely or partially in any way under a penal statute or rule.

• If he is eligible, the SEP lasts for twelve months.
• The SEP starts the day he was released.
• The SEP ends the last day of the twelfth month after his release.

He can choose to have his coverage begin on the first of the month after he signs up, or to have it begin up to six months retroactively (but not before January 1, 2023, or before his release ). If he uses this SEP to enroll in Medicare, he will not owe a late enrollment penalty. To use this SEP, he should contact SSA.

If he then wants to enroll in a Medicare Advantage Plan or stand-alone Part D prescription drug plan, he should contact 1-800-MEDICARE (1-800-633-4227) to learn more about his enrollment period options. He may qualify for a Medicare Advantage or Part D SEP or have other enrollment periods available, depending on when he enrolls in Part B.

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