It’s nice to have choices, and Medicare gives you choices. That’s true for new enrollees, for enrollees who have recently had a life change and for everyone during the Annual Open Enrollment Period (AEP). Sometimes there are so many options that choosing the right Medicare plan can seem daunting. But with a little knowledge, Medicare recipients can make choices that work for them during AEP.
“First, it’s important to remember that the choices you make aren’t set in stone,” says licensed health insurance agent Vince Kelly. He suggests that after initially enrolling in Medicare, individuals who haven’t had any significant medical, financial or personal changes don’t need to review their Medicare coverage every year. Every four or five years is fine.
“If you’re satisfied with your coverage and health care providers, there’s really no need,” he explains. “There are updates to Medicare every year, but they’re generally fairly limited. Unless there are contract changes with medical groups or plans terminating their contract with Medicare. This may occur and members will be notified by mail.”
There may be changes to individual medical groups or policy terms, he adds. In those cases, the affected members are notified by mail.
Next year is no exception. The proposed changes to Medicare in 2026 are minor. For example, the maximum out-of-pocket spending limit for covered prescription drugs will increase by 0.5%, from $2,000 to $2,100. On the upside, free vaccines (previously limited) will become a permanent benefit of Part D plans, covering all adult vaccines recommended by the Advisory Committee on Immunization Practices.
“There are changes,” Kelly says, “but nothing earth-shaking and nothing that should cause people to change their coverage if there are no significant changes to their personal circumstances.”
There are times, though, when it’s a good idea to revisit Medicare coverage. “People worry that once they make a selection, that’s it for life,” Kelly says. “That’s simply not true.”
Outside the AEP, changes in an individual’s personal situation can trigger a Medicare Special Enrollment Period (SEP). These changes include moving to a new county or state, moving into or out of an institution such as a rehabilitation hospital or nursing home, gaining or losing employer or union medical coverage, natural disasters and other circumstances.
Erik Milanez, health insurance agent with YMA Insurance Solutions, Inc., says a common scenario is beneficiaries with Original Medicare and a Medigap supplement who have essentially aged out of that combination. “Those supplements can be very expensive, especially with advancing age,” he explains. “I’ve had several clients in their 70s who can no longer afford their Medigap premiums. These individuals can consider enrolling in a Medicare Advantage HMO plan to reduce their expenses—oftentimes they can keep their doctors or change their insurance plan.”
Medigap supplement plans and Medicare Advantage PPO plans allow enrollees more flexibility in choosing their providers. Medigap plans are where providers bill Medicare, while Medicare Advantage PPO plans replace Original Medicare and an insurance company handles claims.
But, as Milanez points out, “when you have a Medigap supplement or Medicare Advantage PPO, you must be your own health care advocate. There’s no access to a case management team or medical group the way there is for individuals with Medicare Advantage HMOs.”
Medicare Advantage PPOs can also come with “out-of-pocket surprises” that Medicare Advantage HMOs don’t incur, Milanez notes.
“Let’s say you need a procedure and look up the in-network cost. If you schedule the procedure with an out-of-network provider, you can be charged a 40% co-insurance fee.”
While HMOs do limit enrollees’ choice of health care providers, they also limit expenses. And if individuals make an informed choice of HMO, the limits on providers may not be an issue anyway. “I’m on a Medicare Advantage HMO plan,” Kelly notes, “and I love it.”
For more information call Torrance Memorial IPA at 310-517-7239, or licensed independent agents Vince Kelly at 310-625-1837 or Erik Milenaz at 310-715-2300. You can also attend Torrance Memorial IPA’s complimentary Medicare 101 lectures (TorranceMemorialIPA.org/medicare101) for more information.
Medicare’s Annual Open Enrollment Period is October 15 through December 7
During this time, people with Medicare can change their Medicare Advantage or Part D prescription drug plans for the following year. These changes will take effect on 01/01/2026.
New Medicare recipients have an Initial Enrollment Period (IEP) that lasts 7 months; it begins 3 months before the month you turn 65 (or your 25th month of disability benefits), includes your birthday month, and ends 3 months after. During this time you can enroll in Part A, Part B, or both.
If you already have Part A and are adding Part B later, your enrollment window depends on your situation. Many people qualify for a Special Enrollment Period (for example, when leaving employer coverage).
There is also a Medicare Advantage Open Enrollment Period (MA OEP) each year from Jan. 1 through Mar. 31. This allows people already in a Medicare Advantage plan to switch to another Advantage plan or return to Original Medicare.
Each fall, Medicare mails the Medicare & You handbook, and your current plan will send you an Annual Notice of Change (ANOC) by late September, outlining any changes for the upcoming year.
