Medicare open enrollment starts Oct. 15. Here's what to know

Oct. 10—Medicare's fall open enrollment, which runs Oct. 15 through Dec. 7, is an opportunity to review your benefits and make changes for 2025.

Signing up for Medicare or changing plans can seem daunting, but it's important to make sure you're enrolled in the best plan for your medical needs.

To help make the process easier, The Inquirer has curated a Medicare primer based on questions sent in by readers. Now updated for 2025, it can help you select the best Medicare plan for you.

Glossary of terms

1.

Premium: The base cost of the health plan, paid monthly. Regardless of whether you choose original Medicare or Medicare Advantage, you will pay the Part B premium monthly. Most people paid $174.70 a month for the Part B premium in 2024.

2.

Deductible: The amount of money you spend out-of-pocket before the plan begins paying a larger share of medical expenses. For 2024 the Part B deductible was $240.

3.

Copay: A flat fee you pay for certain services, such as a doctor's visit or prescription medication.

4.

Coinsurance: The portion of a medical bill you must pay even after you meet your deductible. Original Medicare has 20% coinsurance after meeting the deductible, which means you will pay 20% of any medical bill.

5.

Drug formulary: The list of prescription medications covered by your plan. Formularies rank medications into tiers, with lower-tier drugs being the preferred and least-expensive options. Higher-tier versions of the same medication will cost more. Health plans frequently switch their preferred choices and may even drop medications from the formulary.

6.

In-network: Doctors who accept your health plan are in-network. The vast majority of doctors accept original Medicare. Medicare Advantage plan networks vary.

7.

Out-of-network: Doctors who do not accept your health plan are out-of-network. You may have to pay more for their services, or the visit may not be covered at all by your plan.

8.

Original or traditional Medicare: A federal health program for people who are 65 or older, or who have a qualifying disability. People who choose original Medicare will enroll in Part B, with choices for optional supplemental and drug plans.

9.

Medicare Advantage: Medicare plans sold and operated by private insurers. These federally approved plans must cover all Plan B benefits. They can offer extra services, such as coverage for prescription drugs, and may limit the number of in-network doctors.

10.

Part A: Covers hospital visits and medications administered in a hospital setting, such as infused drugs. Most people receive Part A coverage when they turn 65 at no additional cost.

11.

Part B: Covers doctor's visits, labs, and other non-hospital services. People who choose original Medicare will enroll in Part B.

12.

Part C: Also known as Medicare Advantage.

13.

Part D: Prescription drug plans that people who opt for original Medicare can buy.

14.

Medigap: Also known as supplemental plans that people who opt for original Medicare can buy to cover out-of-pocket costs, such as copays. Medigap plans do not pay for the Plan B premium.

Annual open enrollment questions

What is Medicare's annual open enrollment?

A time to review your Medicare coverage — whether you have original Medicare with prescription and supplement plans, or Medicare Advantage. During the fall enrollment period, you can sign up for new coverage or change your plan. You can switch from original Medicare to Medicare Advantage (or vice versa), add a prescription drug or supplement plan to original Medicare coverage, or choose a new Medicare Advantage plan.

Do I need to do anything during the fall enrollment period if I'm happy with my current plan?

Yes. Plans may change slightly from one year to the next, so it is important to review your coverage, even if you're happy with it. For instance, the list of prescription medications covered by Medicare Advantage and Part D plans changes every year. Your preferred medication may no longer be covered or the cost may have changed. Also, consider how your health needs have changed: Did you start taking a new medication? Will you be traveling more? Be sure that your current plan is still the best fit.

Medicare 101

What's the difference between original Medicare and Medicare Advantage?

Original Medicare is managed by the federal government and offers coverage for hospital services (Part A) and outpatient services, such as primary care doctors, specialists, and routine care (Part B).

Medicare Advantage plans are run by private insurance companies approved by the federal government. These managed-care plans must cover all the same benefits as original Medicare, though you'll be limited to their provider networks. They may offer extras, such as dental, vision, or hearing services.

Medicare Advantage plans also typically cover prescription medications. People who opt for original Medicare can buy supplemental plans to help cover more health care costs or a Part D drug plan for medications.

How do I know which plan is right for me?

It depends on your medical needs and financial resources.

Original Medicare is accepted by most doctors, which could be important if you need care while traveling out of state. Similar to many employer-based insurance plans, Medicare Advantage plans have provider networks. If you go to an out-of-network doctor or hospital, the visit may not be covered or may cost more.

Use Medicare's online Plan Finder tool or talk to a volunteer counselor (more details on where to get help below) to decide which plan best meets your needs.

What type of plan should I choose if cost is my biggest concern?

It depends. Your total out-of-pocket expense will depend on how the plan you choose covers the services you use most. Both types of plans have a premium for Part B (doctor's services) — about $175 a month for most people in 2024, as well as a deductible, which was $240 in 2024. CMS had not released premium and deductible amounts for 2025 at the time of publication.

Original Medicare beneficiaries pay 20% of the Medicare-approved rate for most doctor services after meeting their deductible. Supplemental plans can help cover some of these extra expenses for original Medicare members.

Copays, coinsurance, and deductibles will vary for Medicare Advantage plans, which may charge additional premiums for its prescription drug coverage and extra services.

Does Medicare restrict which doctors I can see? Can I change doctors?

Always ask before making an appointment, but most doctors accept original Medicare.

Medicare Advantage plans have more limited provider networks. Call your plan to ask for a list of in-network providers. Or ask whether a doctor you already see is in network.

You can switch doctors at any time, but make sure your new doctor is covered by your plan to avoid unexpected bills.

Are there any programs to help people pay for Medicare?

Yes. People who meet income and asset qualifications may be eligible for one of Medicare's financial assistance programs.

1.

The Qualified Medicare Beneficiary program offers the highest level of assistance, helping pay for Part A and B premiums, deductibles, coinsurance, and copays for people with $1,275 or less in monthly income and no more than $9,430 in assets. Income and assets requirements may vary by state and are higher for couples.

2.

The Specified Low-Income Medicare Beneficiary helps people who earn too much to be eligible for the QMB program to pay for their Part B premiums.

3.

The Qualifying Individual program also helps cover Part B premiums, has an even higher income threshold, and is available on a first-come, first-served basis.

4.

The Qualified Disabled and Working Individuals program helps cover Part A premiums for people younger than 65 with a disability who are currently working.

5.

Medicare beneficiaries in New Jersey may also be eligible for state-run assistance to make prescription drugs more affordable.

The National Council on Aging has a website called BenefitsCheckUp to help people research these options.

Enrolling in coverage

How do I choose supplemental coverage?

Pick a plan to address the coverage gaps that concern you the most. Supplemental coverage is for people with original Medicare; it cannot be used to cover Medicare Advantage out-of-pocket expenses.

Supplemental coverage, also called Medigap, covers "gaps" in original Medicare plans, such as health expenses while traveling abroad, excess charges, or copays. It is sold by private insurance companies. Look for a letter system to assemble your benefits package; plans with the same letter offer the same coverage.

Be aware that prices can vary widely between companies, even for the same coverage.

How do I figure out which prescription plan will be the lowest cost to me?

Make sure it covers the drugs you need.

Most people focus on the monthly cost, known as the plan premium. But a plan with a low premium could end up costing more than another with a pricier premium if it does not cover your specific medications. Also review cost-sharing details — how much you will pay versus how much the plan will pay — and whether you will be required to fill prescriptions at select pharmacies. Medicare's Plan Finder allows you to search based on the medications that you need.

Where can I go for help?

Don't be surprised if you need advice. The options can get complicated and scams abound during enrollment season.

Every state has an agency offering free Medicare help. These impartial programs do not offer legal advice, endorse plans, or sell insurance.

1.

Pennsylvania Medicare Education and Decision Insight (PA MEDI), formerly called the APPRISE program, has a help line and locations across the state providing personalized assistance. Learn more at aging.pa.gov, or call 800-783-7067.

2.

New Jersey State Health Insurance Assistance Program also has a help line and local offices with volunteer counselors. Find locations at nj.gov/humanservices/doas/services/q-z/ship/, or call 800-792-8820.

3.

Nonprofit organizations such as CARIE (Center for Advocacy for the Rights and Interests of the Elderly) also provide assistance. Independent brokers, who are not bound to sell just one insurer's products, can also be a good resource.

How do I find a reputable independent broker?

Find licensed brokers using the online database maintained by the National Association of Insurance Commissioners. The National Association of Benefits and Insurance Professionals also has an online database to find agents.

Independent brokers must be licensed by the state and follow strict rules about selling private Medicare plans (Medigap, drug, and Advantage plans). Search for a broker who lives in your community, rather than several states away, if you wish to meet in person.

Drilling down into Medicare

What if I don't sign up during my 'new to Medicare' period?

You could face penalties.

Most people qualify for Medicare at 65. There's a seven-month period to sign up — your birth month plus three months before and after. Sign up early if you want coverage to start as soon as you turn 65. Missing this enrollment period could lead to penalties for the duration of your Medicare coverage.

The penalty for signing up late to Plan B is 10% of the premium for every 12 months you were not enrolled. Part D prescription coverage has a penalty of 1% of the premium for every month missed. If you miss your "new to Medicare" enrollment period, you could end up temporarily uninsured.

What if I plan on working past 65 and have employer-sponsored coverage?

You can usually keep your health plan and delay enrolling in Medicare without penalty.

People who have health insurance through a large employer — and are actively working — can delay signing up for Part B until they retire without penalty. If you have coverage through a small company with fewer than 20 people, you'll have to move to Medicare.

Talk to your human resources department about your options. If you keep your employer-sponsored health plan beyond age 65, your employer will need to fill out a form verifying you had continuous coverage when you retire.

The same rules apply if you are covered under a private health plan through a spouse who is still working.

How do I decide whether to keep my employer-sponsored health plan or transition to Medicare?

Consider the premium, deductible, and other cost-sharing expenses. Compare how prescriptions are covered and the doctor networks offered. If you are covered under a spouse's plan, look at how the employer handles dependent coverage.

Companies may pay for a large share of the employee's health insurance but not the cost of insuring spouses and children. In this case, it may be more cost-effective for an over-65 spouse to move to Medicare.

Can a spouse's health savings account from an employer-sponsored health plan cover my Medicare expenses?

Yes — with limits.

An employee's HSA can be used to pay eligible medical bills for a spouse covered by Medicare. Eligible medical expenses include copays for prescriptions and services applied to your plan's deductible, as well as Part A and Part B premiums. An HSA cannot be used to pay for supplemental policy premiums. Once you sign up for Medicare, however, you will no longer be allowed to contribute pretax funds to an HSA.

What if I have an individual health plan through the Affordable Care Act marketplace?

People with ACA marketplace health plans almost always transition to Medicare when they turn 65. You may be able to keep your individual health plan, but you won't be eligible for a tax subsidy after 65 and could face penalties if you don't sign up right away.

The cost and coverage could be very different from what you're used to. The Medicare Part B premium may be less than what people in their 60s pay for an individual marketplace plan. But people who have been receiving an income-based tax subsidy for an ACA marketplace plan may find that their costs rise under Medicare.

Consider discussing options with an enrollment adviser, or visit the National Council on Aging's BenefitsCheckUp website to find out if you're eligible for financial assistance.

What are zero-dollar premium Medicare Advantage plans and are they really free?

No. Everyone pays a monthly premium for Part B, regardless of whether you have original Medicare or Medicare Advantage.

Medicare Advantage plans often include extra services, such as prescription drugs, vision, or dental — for an extra charge. When a plan advertises a "zero-dollar premium," it is referring to these additional, plan-specific benefits. You will still pay the Part B premium.

Keep in mind that premiums are only one source of out-of-pocket costs. Plans with low premiums may have high deductibles, copays, and coinsurance. You should also consider how much your medications will cost under the plan and whether your doctors are in network. Medicare's online plan finder can help you compare options.

What is Silver Sneakers?

A fitness program offered by some Medicare Advantage plans that gives members access to free gym memberships, fitness classes, and health education resources. It is not part of original Medicare. Plans that don't offer Silver Sneakers may have a similar fitness program. Ask your plan administrator.

Although the program can be a valuable benefit, also consider whether the plan will meet your health-care needs, how it covers the medications you take, and whether you can continue seeing the same doctors. And, as with any fitness membership, make sure that the facility fits your physical needs, schedule, and location.

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