Table of Contents Expand Table of Contents During open enrollment, you can decide between Medicare Advantage, and Original Medicare with Medigap. triloks / Getty Images Close Key Takeaways Original Medicare (Part A and Part B) has its upsides. Unlike Medicare Advantage, it doesn't limit you to using a particular provider network. You can get care at almost all U.S. hospitals and doctor offices, and you rarely need prior authorization for medical services or supplies. Warning Six states are testing pre-autho ...

Core Insights - The article emphasizes the importance of understanding the potential drawbacks of switching from original Medicare to Medicare Advantage plans during the fall open enrollment period [1][11] Group 1: Medicare Advantage Benefits - Medicare Advantage plans can limit annual out-of-pocket spending and often provide additional services not covered by original Medicare, such as dental care, eye exams, and hearing aids [2] - Access to more covered benefits through Medicare Advantage could help retirees manage healthcare costs, especially for those relying primarily on Social Security for income [3] Group 2: Potential Drawbacks of Medicare Advantage - The $0 premium trap: Many Medicare Advantage plans advertise $0 premiums, but beneficiaries still need to pay for Medicare Part B and may face additional costs through copays, deductibles, and coinsurance [4][5] - The limited provider network trap: Unlike original Medicare, which allows access to any doctor accepting Medicare, Medicare Advantage typically restricts beneficiaries to a specific network of providers, which can complicate care access, especially for those who travel frequently [6][7][8] - The prior authorization trap: Medicare Advantage plans often require prior authorization for higher-cost services, which can lead to delays and denials in care. The Kaiser Family Foundation reports that 99% of Medicare Advantage enrollees are subject to this requirement, compared to a limited number of services under original Medicare [9][10]

Core Insights - Healthcare costs are a significant factor in retirement budgeting, making it essential to select the appropriate Medicare coverage [1] - Medicare Advantage plans often provide additional benefits and cost caps compared to original Medicare, which is crucial for retirees on fixed incomes [2] Group 1: Medicare Advantage Plans - Medicare Advantage plans may offer supplemental benefits that original Medicare does not cover [2] - These plans typically have an out-of-pocket maximum, which can help manage healthcare expenses for retirees [2] - It is important for retirees to review their Medicare Advantage plan options annually to avoid unnecessary costs and aggravation [3] Group 2: Open Enrollment Period - The Medicare fall open enrollment period is currently active, allowing changes to Medicare coverage until December 7 [4] - Retirees should consider switching to a new Medicare Advantage plan if their current plan's costs are increasing without additional benefits [6] - Changes in plan benefits for the worse or shifts in healthcare needs are valid reasons to explore new Medicare Advantage options during this enrollment period [8][9]

Core Insights - The article discusses the complexities and changes in Medicare Advantage plans, emphasizing the importance of understanding the benefits and costs associated with different plans offered by private insurers [1][2][3]. Group 1: Medicare Advantage Overview - Medicare Advantage, also known as Part C, is a Medicare-approved plan provided by private insurers that combines hospital insurance (Part A), medical insurance (Part B), and usually prescription drug coverage (Part D) into a single package [2]. - The number of Medicare Advantage plans has decreased, and many plans have weakened in terms of benefits, creating challenges for beneficiaries during the open enrollment period [3]. Group 2: Enrollment and Costs - From October 15 to December 7, beneficiaries can enroll in, switch, or drop Medicare Advantage or drug plans, or revert to Original Medicare [2]. - In 2025, over 76% of enrollees in individual Medicare Advantage plans with drug coverage paid no premium beyond the standard Part B premium [7]. - The annual out-of-pocket maximum for Medicare Advantage plans in 2025 is capped at $9,350 for in-network services and $14,000 for combined in- and out-of-network services, with average out-of-pocket maximums of $5,320 for in-network care and $9,547 for PPO plans [8]. Group 3: Choosing the Right Plan - Beneficiaries should focus on total healthcare costs rather than just premiums, as a $0-premium plan may end up costing more in the long run due to higher out-of-pocket limits [9]. - It is crucial to ensure that all necessary prescriptions are covered in the chosen plan, as this significantly impacts annual out-of-pocket costs [5][9]. - Additional benefits such as vision, dental, and gym memberships can influence the decision, but their importance varies by individual needs [6]. Group 4: Understanding Coverage and Penalties - Beneficiaries without prescription drug coverage face a Part D penalty, which is a permanent surcharge added to monthly premiums if they go without coverage for 63 days or more after their initial enrollment period [4]. - Insurers cannot deny coverage based on health status, ensuring that individuals can enroll in Medicare Advantage plans regardless of their healthcare needs [11]. Group 5: Consumer Protection - Scammers often target older adults during open enrollment with misleading ads and calls, highlighting the need for vigilance and verification of caller credentials [11][12]. - Consumers can verify the legitimacy of callers by asking for their National Producer Number (NPN) and checking it through their state insurance commissioner's office [13].

Core Insights - Medicare Advantage enrollment is projected to decline to 34 million subscribers in 2026, down from 34.9 million in 2025, resulting in a market share drop from 50% to approximately 48% [1][2] - The Centers for Medicare and Medicaid Services (CMS) expects enrollment to be more stable than projected, contrasting with the historical growth trend where Medicare Advantage captured 25% of the market in 2010 and has gained share annually since then [2][3] - The upcoming open-enrollment period from October 15 to December 7 may influence beneficiaries to reassess their health and drug coverage due to rising healthcare costs and recent political events affecting healthcare affordability [4] Industry Trends - Medicare Advantage plans have historically expanded benefits, but current focus has shifted towards profitability rather than growth, potentially leading to less generous benefits and a shift back to original Medicare among seniors [6] - The political climate, including the recent federal government shutdown, may impact beneficiaries' decisions regarding their healthcare plans, as they seek to manage costs amid uncertainty [4][5]