If you’re turning 65 soon—or you’re already on Medicare—you’ll hear a lot about Medicare Open Enrollment every autumn. There’s a good reason: each year from October 15 to December 7, you get a window to review your coverage and make changes for the coming year. Plans update benefits, premiums, provider networks, and prescription drug lists annually. A quick, thoughtful review can prevent surprise costs on January 1 and help you get more from your coverage.

This guide explains what Medicare is, how the parts fit together, and exactly why taking time each fall to reassess your plan is so important. It’s written in plain English, with practical steps you can use right away.

Medicare is the federal health insurance program primarily for:

• People 65 and older
• People under 65 who qualify because of certain disabilities
• Individuals with End-Stage Renal Disease (ESRD) or ALS

Medicare is organized into parts. Think of them like building blocks you combine to create the coverage you want.

Medicare Part A (Hospital Insurance)

Helps pay for inpatient hospital stays, skilled nursing facility care after a qualifying hospital stay, hospice care, and some home health services. Most people don’t pay a monthly premium for Part A if they or a spouse worked and paid Medicare taxes long enough.

Medicare Part B (Medical Insurance)

Helps pay for doctor visits, outpatient care, preventive services, durable medical equipment, and more. Part B has a monthly premium and cost-sharing (like an annual deductible and coinsurance).

Original Medicare = Part A + Part B

You can see any provider nationwide who accepts Medicare, and referrals are typically not required. However, Original Medicare doesn’t cover everything, and there’s no annual out-of-pocket maximum, which is why many people add other coverage.

MedicarePart D (Prescription Drug Coverage)

Stand-alone plans that pair with Original Medicare (A + B) to help cover prescription medications. Each plan has its own formulary (list of covered drugs) and rules such as tiers, preferred pharmacies, prior authorization, and step therapy.

Medicare Advantage (Part C)

Offered by private insurers and bundles Part A and Part B (and often Part D) into one plan. Many Medicare Advantage (MA) plans include extra benefits not covered by Original Medicare (for example, certain dental, vision, hearing, or fitness perks) and they set an annual out-of-pocket maximum for Part A and B services. Most MA plans use provider networks (HMO or PPO).

Medigap (Medicare Supplement Insurance)

Private policies that work only with Original Medicare (A + B). A Medigap plan helps pay some out-of-pocket costs like coinsurance, copays, and deductibles. You can’t use Medigap with Medicare Advantage. Medigap options and rules vary by state, and the best time to buy is often when you first enroll in Part B (you’ll generally have a guaranteed-issue window).

Understanding the timing rules keeps you away from late fees and gaps in coverage.

• Initial Enrollment Period (IEP) A 7-month window around your 65th birthday: it starts 3 months before your birth month, includes your birth month, and ends 3 months after. Most people enroll in Parts A and B here. If you’re still working and have creditable employer coverage, your timing might be different—more on that below.
• Special Enrollment Periods (SEPs) If you (or your spouse) delay Part B and/or Part D because you have creditable employer coverage, you can generally enroll later without penalties when that coverage ends. Other SEPs can apply for moves, plan contract changes, or qualifying life events.
• General Enrollment Period (GEP) If you miss your IEP and don’t qualify for an SEP, you can enroll in Part A and/or Part B January 1–March 31 each year, with coverage starting soon after. Late enrollment penalties may apply.
• Annual Enrollment Period (AEP/Open Enrollment) October 15–December 7 every year. This is your primary window to switch between Medicare Advantage and Original Medicare, change Part D plans, or move from one Medicare Advantage plan to another for the following year (January 1 start date).
• Medicare Advantage Open Enrollment Period (MA OEP) January 1–March 31. For people already in a Medicare Advantage plan, this period allows a one-time change to another MA plan or a switch back to Original Medicare (with or without a Part D plan). It does not apply if you have Original Medicare.

Getting the timing right avoids late enrollment penalties, which can be permanent for Part B and Part D. That’s one of the biggest reasons people seek guidance early.

Medicare costs have several layers:

Medicare Premiums

• Part A: Many people pay $0; others may pay a premium depending on work history.
• Part B: Monthly premium is set annually and may be adjusted if your income is higher.
• Part D: Varies by plan.
• Medicare Advantage: Some plans have a $0 premium (you still pay your Part B premium), others charge an additional premium.

Cost Sharing

Deductibles, copays, and coinsurance differ by plan type. Original Medicare typically uses a deductible and 20% coinsurance for many Part B services. Medicare Advantage plans set their own copays/coinsurance within federal rules and include an annual out-of-pocket maximum for Part A and B services.

IRMAA (Income-Related Monthly Adjustment Amount)

Higher-income beneficiaries may pay an additional amount on top of Part B and/or Part D premiums. This is based on your tax return from two years prior. If your income drops due to certain life-changing events, you can ask Social Security to reconsider.

Medicare and Prescription Drug Spending

Part D plans vary widely in how they price drugs—each has its own tiers and preferred pharmacies. Small differences in formularies and pharmacy networks can mean large differences in yearly costs.

Because each piece affects your total out-of-pocket amount, plan selection should look at the whole year, not just the monthly premium.

Both paths are legitimate; the better option depends on your needs and preferences.

Original Medicare + (Optional) Medigap + (Optional) Part D

Pros

• Wide provider choice nationwide among providers who accept Medicare.
• No referrals typically required.
• With Medigap, you can predict many out-of-pocket costs more easily.

Considerations

• You’ll likely need a standalone Part D plan for medications.
• Medigap premiums vary and can increase with age; underwriting may apply if you try to buy later (outside guaranteed-issue windows).
• Original Medicare does not include an annual out-of-pocket max on its own; Medigap is what helps cover many gaps.

Medicare Advantage (Part C)

Pros

• All-in-one plan; often includes Part D.
• Annual out-of-pocket maximum for Part A and B services.
• May include extra benefits such as certain dental, vision, hearing, OTC allowances, and fitness.

Considerations

• Provider networks (HMO/PPO). Out-of-network care can cost more or may not be covered (HMO).
• Prior authorization is common for some services.
• Benefits, formulary, and networks can change each year—review is crucial every fall.

If you stay with Original Medicare, you can add a standalone Part D plan. If you enroll in a Medicare Advantage plan that includes drug coverage, you’ll use that plan’s Part D benefit.

What matters most:

• Your exact medications and dosages
• Your preferred pharmacies
• Any mail-order preferences
• Whether the plan requires prior authorization, quantity limits, or step therapy for your drugs

Plans group medications in tiers. Lower tiers usually have lower copays. The same drug can be on different tiers in different plans, which is why reviewing each fall can save real money.

Late enrollment penalty warning: If you go 63+ days without creditable drug coverage after your IEP, you could pay a permanent late penalty added to your Part D premium when you eventually enroll.

Medigap plans are standardized in many states (for example, Plans G, N, etc.), meaning the benefits of each lettered plan are the same regardless of the company offering it. You pay a monthly premium for Medigap, and it helps cover Original Medicare’s cost-sharing. In most states, the best time to enroll is during your Medigap Open Enrollment Period—the 6 months that start when you’re both 65+ and enrolled in Part B. During that window, you generally have guaranteed issue rights (no medical underwriting). After that, depending on your state, carriers might review health history and can accept or decline your application or charge more.

If you’re considering a move from Medicare Advantage back to Original Medicare and you want a Medigap plan, ask early about whether you’ll qualify and what your options are. Some states have additional protections or special windows; others do not.

Plans are allowed to revise their benefits, provider networks, pharmacy contracts, and drug formularies every year. Your situation may have changed too. Reviewing during October 15–December 7 helps you:

1.  Avoid surprise drug costs in January.
   A medication that was Tier 3 this year might move to Tier 4 next year, or require prior authorization, or no longer be covered.
2. Verify your doctors and hospitals.
   In Medicare Advantage plans, networks can change. Your preferred specialists or hospital could leave the network for the upcoming year.
3. Check premiums and copays.
   Small premium changes add up over 12 months; so do copays for frequent services (like primary care visits, specialist visits, physical therapy, or diagnostic imaging).
4. Evaluate your annual out-of-pocket maximum (Medicare Advantage).
   If the maximum is increasing, or you anticipate more care, compare alternatives.
5. Confirm extra benefits you actually use.
   Dental allowances, eyewear stipends, hearing aid benefits, over-the-counter (OTC) credits, and fitness programs can change—or another plan may offer benefits that matter more to you.
6. Align coverage with new health needs.
   A new diagnosis, a planned surgery, or more frequent specialist visits can change which plan design suits you best.
7. Plan for travel and seasonal living.
   If you split time between states, network flexibility and out-of-area coverage become more important. Some PPO or regional PPO options may fit better; Original Medicare with Medigap is another path many “snowbirds” consider.
8. Avoid late penalties or gaps if your situation changed.
   Retiring this year? Losing employer coverage? Moving? These can trigger Special Enrollment Periods and change your next-best step.

A smart fall review can be the difference between smooth, predictable coverage and costly surprises.

If you’re already in a Medicare Advantage or Part D plan, watch for the Annual Notice of Change (ANOC) each fall (typically by the end of September). It outlines what’s changing in your current plan for the upcoming year—premiums, copays, formulary updates, network notes, and more.

What to do when you get your ANOC:

• Compare this year’s costs and rules to next year’s.
• Circle any changes to your regular services and prescriptions.
• If you see a red flag—like a key medication moving to a higher tier or a provider leaving the network—start comparing alternatives immediately.

Use this simple sequence to evaluate your Medicare coverage every October–November:

1. List your current providers.
   Include primary care, specialists, therapists, preferred hospitals/clinics, and any upcoming procedures.
2. Gather a current medication list.
   Name, dosage, frequency, and your preferred pharmacies (retail and mail-order). Note any new prescriptions or changes this year.
3. Add your health goals and upcoming needs.
   For example: “knee replacement likely in spring,” “need updated hearing aids,” or “traveling out-of-state for 3 months.”
4. Decide what matters most. Lower premiums?
   Lower out-of-pocket risk? Strong dental/vision benefits? Broadest network? Minimal prior authorization? Rank your priorities.
5. Review your ANOC (if you have one).
   Flag changes that affect you.
6. Check plan networks.
   For Medicare Advantage, verify that your providers and preferred hospital are in-network for next year.
7. Run a drug comparison.
   Look at total annual costs for your exact drugs across candidate plans, considering tiers and preferred pharmacies.
8. Look at maximum out-of-pocket (MA plans).
   If you anticipate more care, paying a slightly higher premium for a lower maximum may be worthwhile.
9. Scan extra benefits (if you use them).
   Dental allowances, hearing aid benefits, OTC credits—these can tip the scales when medical coverage is otherwise similar.
10. Check travel flexibility.
    If you winter in another state, does the plan cover out-of-area services? Would a PPO or Original Medicare + Medigap fit better?
11. Save your top two options.
    Side-by-side comparisons make the final decision easier.
12. Confirm enrollment mechanics and dates.
    If switching, submit your application during October 15–December 7 so coverage starts January 1.

Myth #1: “I’m healthy; I don’t need to review annually.”

Even if you rarely see a doctor, plan drug lists, premiums, and copays change. A plan that looked great last year might be less competitive next year. A quick review can preserve your savings without costing you time all year long.

Myth #2: “I can buy a Medigap plan whenever I want, no problem.”

You can apply anytime in many states, but outside guaranteed-issue periods, companies may review your health history and can deny or rate your application. The timing around your Part B start is often critical.

Myth #3: “I don’t take medications, so I’ll skip Part D.”

If you go without creditable drug coverage and later need Part D, you could face a permanent late-enrollment penalty. Many people choose an affordable plan now to protect against future penalties and unexpected prescriptions.

Myth #4: “Medicare covers long-term custodial care.”

Medicare may cover skilled care for limited durations, but custodial long-term care (help with activities of daily living) is generally not covered. Planning for potential long-term care needs is a separate conversation.

The Snowbird Couple

They live up north most of the year and spend winters in Florida. They value provider flexibility while traveling, don’t want to worry about out-of-network bills, and want predictable costs. Original Medicare + Medigap + Part D often rises to the top for this lifestyle, though a broad PPO could work if their Florida providers participate.

The New Diagnosis

A beneficiary is newly diagnosed with diabetes and sees multiple specialists. The plan that’s best next year might be the one with lower specialist copays, predictable costs for lab work and supplies, and strong coverage for their insulin and other medications—sometimes that’s a specific Medicare Advantage plan; other times it’s Original Medicare + Medigap + a Part D plan with excellent drug coverage.

The VA-Eligible Veteran

VA benefits can work alongside Medicare. Many choose to keep Part A and Part B to access civilian providers when needed and use the VA for medications or specialty services. The right combination depends on how often they want to use non-VA providers and their preferred pharmacies.

The Caregiver’s Dilemma

An adult child helps a parent who takes several brand-name medications. A yearly drug comparison often reveals meaningful savings—sometimes by switching to a plan with a better formulary tier placement or a different preferred pharmacy arrangement.

When you’re deciding between Original Medicare + Medigap and Medicare Advantage, ask:

• How important is nationwide flexibility?
  If you travel or split time between states, broad access may matter most.
• Do you prefer predictable costs or lower premiums?
  Medigap may provide predictable out-of-pocket spending for Part A and B services, while some MA plans keep premiums very low but use copays as you go.
• How do your current drugs price out?
  Run the math using your exact list—brand-name vs. generic placement can change the totals by thousands over a year.
• What’s your tolerance for prior authorization and referrals?
  Some people don’t mind working within plan rules; others prefer fewer hoops to jump through.
• Do you actively use dental, hearing, or fitness benefits?
  If you do, those extras could tip you toward a particular MA plan. If you don’t, let the core medical and drug math drive the decision.

Do I need both Medigap and Part D?

If you’re on Original Medicare, Medigap helps with medical cost-sharing and Part D addresses prescriptions. They cover different things; many people have both.

Can I keep my doctor with Medicare Advantage?

Often yes—if your doctor is in the plan’s network. Always verify network participation for next year during fall review.

Are telehealth services covered?

Many services are covered under Medicare with certain rules; coverage specifics can vary by plan and may evolve. Check your plan’s current policy during fall review.

What if I still have employer coverage at 65?

If your employer coverage is creditable, you may be able to delay Part B and/or Part D without penalties. When that coverage ends, you may qualify for a Special Enrollment Period. It’s worth confirming details with a licensed agent to avoid gaps.

Can I switch from Medicare Advantage to Original Medicare later?

Yes, during AEP (Oct 15–Dec 7) or MA OEP (Jan 1–Mar 31). If you want a Medigap plan, check whether you’ll have guaranteed-issue rights in your state or if underwriting would apply.

Will Medicare cover my upcoming procedure?

Coverage depends on whether you’re in Original Medicare or Medicare Advantage, how the service is billed, medical necessity, and plan rules. This is where confirming codes, authorizations, and network status can prevent surprises.

• Late September: Watch for your ANOC in the mail or online.
• October 1–14: Build your provider and medication checklist and run preliminary comparisons.
• October 15–December 7: Enroll in your chosen plan for coverage starting January 1.
• January: Verify your plan ID card, pharmacy setup, and any referrals or authorizations you’ll need early in the year.

Even if you decide to stay with your current plan, the review confirms that it’s still a good fit. If you discover a better option, you’ll have time to switch before the window closes.

Medicare isn’t one-size-fits-all. A licensed Medicare agent can:

• Translate plan jargon into plain language and focus on your priorities.
• Run side-by-side comparisons using your providers and current prescriptions.
• Verify network participation and pharmacy tiers—two areas that often drive real costs.
• Explain timing rules (IEP, SEP, AEP, MA OEP) so you don’t miss key windows.
• Help you think through trade-offs: lower premium vs. lower out-of-pocket risk, flexibility vs. extras, and how plan rules (like prior authorization) may impact your care.
• Assist with enrollment and make sure your new coverage starts smoothly on January 1.

The goal isn’t to push a particular plan; it’s to help you choose a setup that aligns with your health, budget, and lifestyle.

• Not connected with or endorsed by the U.S. Government or the federal Medicare program.
• Plan availability, benefits, premiums, pharmacy networks, and drug formularies can change each year.
• Actual costs depend on your chosen plan, your usage, and your eligibility for programs such as Extra Help.
• For personalized advice on your situation, speak with a licensed agent who can review your options and applicable enrollment periods.

• Medicare is the foundation of health coverage for people 65+ and some under 65 with disabilities.
• You’ll combine parts (A and B) and decide whether to add Part D and possibly Medigap, or choose an all-in-one Medicare Advantage plan.
• The Annual Enrollment Period (Oct 15–Dec 7) is when you review and make changes for the upcoming year.
• Because plans and personal needs change, an annual fall review protects your budget and your preferred providers.
• Getting guidance can save time, frustration, and money by aligning coverage with how you actually receive care.

Bring your provider list, medication list, and your goals for the year ahead—even if your goal is simply “no surprises.” If you’d like a personalized comparison, we can walk you through your options step by step and help you enroll in time for your January 1 start date.