October 2025

Each year from mid-October through early December, Medicare enrollees have a window to make changes to their coverage. This article provides a guide for reviewing your Medicare and supplemental coverage.

At the end of this article, we provide a helpful “Should I Change My Medicare Coverage?” flowchart which you can download.

For plan year 2026, the Annual Open Enrollment Period (AEP) runs October 15 through December 7.

During this time, you can:

• Switch from Original Medicare + Part D to a Medicare Advantage plan
• Switch from one Medicare Advantage plan to another
• Drop Medicare Advantage and go back to Original Medicare (although in most states – except MA, CT, ME, and NY – Medigap insurers are not required to sell you a policy after your first year on Medicare if you don’t meet the medical underwriting requirements)
• Enroll in or change a Part D (prescription drug) plan

If you already have Medicare, this is your annual chance to reassess whether your coverage still meets your needs.

What Original Medicare Enrollees Should Review 

If you are enrolled in Original Medicare (Parts A & B), here’s what your annual review should focus on:

Part D Drug Coverage

• Setting up and reviewing your account at www.medicare.gov can be very helpful in comparing plans.
• Are your current medications still covered?
• Do the copays, coinsurances, and coverage tiers change for next year?
• Is your preferred pharmacy network still included?

Medigap / Supplement Policy Changes 

• Some insurers may raise premiums or adjust rate classes.
• In most states (except MA, CT, ME, and NY,) once your Medigap enrollment period is over, you may not be able to switch without medical underwriting, so changes are harder later.
• If your plan offers rate “community-rated” options or age-based rates, check how your premium may change.

Part B / Cost Increases & IRMAA 

• Expect the standard Part B monthly premium to rise to approximately $206.50 in 2026; higher-income beneficiaries may face steeper surcharges (in Medicare-speak, IRMAA: Income-Related Monthly Adjustment Amount)
• Also review the Part B deductible and coinsurance changes in your 2026 “Medicare & You” handbook.

Providers & Networks 

• Even though Original Medicare generally allows you to see any provider who accepts Medicare, certain supplemental or supplemental plan services (e.g. preventive benefits) may change coverage rules.
• Ensure your preferred physicians and hospitals still accept Medicare under the same terms.

Total Cost Projection

Your Medicare.gov account can help you:

• Add up your premiums (Parts B, Part D, Medigap) + estimated out-of-pocket (copays, deductibles) + travel/foreign care exposure.
• Compare competing Part D or Medigap policies in your area for cost savings.

What Medicare Advantage Enrollees Should Review 

If you currently have a Medicare Advantage (MA / Part C) plan, here’s a checklist:

Annual Notice of Change (ANOC) & Evidence of Coverage (EOC) 

• These notices typically arrive in September. They list changes in premiums, drug formularies, cost sharing, provider networks, and benefits.
• Review them carefully. If your plan’s changes make it worse for you (higher costs, your doctors dropped, drugs removed), consider switching.

Doctor / Hospital Network 

• Confirm that your preferred providers remain in-network under the plan for 2026.
• If your doctors shift networks, your costs could increase substantially.

Drug Coverage / Formulary Changes 

• Some drugs may be removed, moved to higher tiers (more costly), or require step therapy or prior authorization.
• Check whether your current pharmacy is still a “preferred” or in-network pharmacy.

Premiums, Deductibles, and Maximum Out-of-Pocket

• Even if your monthly premium stays low, changes elsewhere (higher outpatient copays, specialist costs, or hospital deductibles) can change your financial outcome.
• Also watch for plan design changes (e.g. shifting benefits to coinsurance vs fixed copays).

Supplemental / Extra Benefits 

• Many Medicare Advantage plans include extras (dental, vision, hearing, wellness, transportation). However, insurers are under budget pressure and may reduce or eliminate some supplemental benefits.
• Verify whether extras that matter to you remain part of the plan.

What’s Changing in 2026 (What to Watch For) 

Looking ahead to plan year 2026 for Medicare, here are some of the major shifts and pressures to be aware of:

Insurer Exits / Plan Reductions

• Several major carriers (Aetna, Elevance, UnitedHealthcare) are scaling back their Medicare Advantage or prescription drug plan presence in some markets.
• When a plan you’re enrolled in is discontinued, you’ll get a Special Enrollment Period (SEP) to choose a new plan. Some states also allow guaranteed issue rights to enroll in Medigap in that scenario.
• This website is one way to search for a new plan: medicareresources.org

Changes to Drug Pricing and Part D 

• The Inflation Reduction Act allows Medicare to negotiate certain prices for certain high-cost prescription drugs (Eliquis, Enbrel, Entresto, Farxiga, Imbruvica, Januvia, Jardiance, Flasp/Novolog, Stelara, Xarelto) starting in 2026.
• The out-of-pocket cap for Part D will increase (e.g., from $2,000 to $2,100) in 2026.
• Some insurers may face lower federal subsidy support, leading to premium increases or tighter formularies.

Premium Changes 

• While average MA plan premiums are expected to decline (or remain stable) in many areas, other costs may still rise (Part B premium increases, drug or service cost sharing).
• Part B premium increases are expected; some sources project it could reach ~$206.50 in 2026 (though that’s not yet final).

Benefit Reductions & Tighter Coverage

• Some insurers may reduce supplemental benefits (transportation, over-the-counter allowances, meal delivery) to preserve margins.
• Expect more restrictive prior authorization or utilization management in some plans.

You can find more information through this link: 10 Major Medicare Changes Coming in 2026

Tips for Choosing Wisely During Open Enrollment

• Start early — don’t wait until December. Review your ANOC/EOC as soon as you receive them.
• Use the Medicare Plan Finder at www.medicare.gov to compare all available plans in your ZIP code, using your actual drug list and preferred providers.
• Contact your State Health Insurance Assistance Program (SHIP) — free local counseling. In Massachusetts, this program is known as SHINE.
• Create a short “must-have list” for coverage (e.g. your physicians’ network, essential drugs, maximum acceptable cost increases) and screen plans against that list.
• Don’t just look at the monthly premium — total cost matters: premiums + cost sharing (copays, coinsurance, deductibles) + network adequacy.
• If your current plan is being discontinued, act quickly in the Open Enrollment period to select a new plan before coverage gaps arise.
• Document all your enrollment decisions, take screenshots, or save confirmation numbers — mistakes happen.

The flowchart below is a guide that helps you determine if you should change your Medicare coverage during open enrollment. Click on the image to download or print the chart.

-SM

If you’re approaching 65, now is the perfect time to understand the Medicare rules and options so you don’t miss important deadlines. This article walks you through what you need to know as you prepare to enroll.

At the end of this article, we provide an “Am I Eligible for Medicare?” flowchart which you can download.

Who Needs to Sign Up for Medicare? 

• Most people become eligible for Medicare at age 65.
• If you are retired and not covered by an employer health plan, you’ll need to enroll in both Medicare Part A (hospital coverage) and Part B (medical/outpatient coverage) during your initial enrollment window.
• If you are still working at age 65, you should enroll in premium-free Medicare Part A while you have employer coverage, as it won’t affect your job-based insurance and can offer secondary coverage without a penalty.
• If you are 65, working, and covered by your (or your spouse’s) large employer health plan (20+ employees), you can delay Part B without penalty until you leave that employer coverage. You’ll have a Special Enrollment Period (SEP) for Part B that lasts until 8 months after your or your spouse’s employment or employer coverage ends.
• If your employer is smaller (fewer than 20 employees), Medicare generally becomes your primary insurance at 65, and you’ll need to sign up for both Medicare A and B to avoid gaps in coverage.

When Should You Sign Up? 

• Your initial enrollment period is a 7-month window around your 65^th birthday: the three months before your 65th birthday, the month of your birthday, and the three months after.
• Signing up before your birthday month ensures coverage starts as soon as you’re eligible.
• If you delay and don’t have other qualifying coverage, you may face late enrollment penalties that last for life. 

What Will Medicare Cost in 2026?

• Part A (Hospital Insurance): Generally premium-free if you or your spouse worked 10+ years.
• Part B (Medical Insurance): The standard premium is projected to be $206.50/month in 2026 (up 11% from the 2025 premium of $185/month.)
• Higher-income households may pay more due to IRMAA surcharges. With rising healthcare costs, it’s wise to budget for increases over time.

Original Medicare vs. Medicare Advantage 

Medicare Parts A (hospital) & B (outpatient) generally cover about 80% of health care charges in these two categories of care. Most people buy additional insurance to cover the remaining costs of care.

You will need to make a choice between two ways to get benefits to supplement Medicare A & B when you sign up. Below are more details on the two categories of Medicare.

Original Medicare

Original Medicare with a Medigap (supplement) policy offers the widest choice of doctors and hospitals since you can see any provider nationwide who accepts Medicare.

It works especially well if you travel frequently, are a “snowbird”, or want the flexibility to see specialists without referrals.

Pairing Original Medicare with a Medigap policy can help cover deductibles, coinsurance, and copays, giving more predictable out-of-pocket costs.

Most people also need to buy a separate Part D prescription plan, and total monthly premiums (Medicare + Medigap + Part D) can be higher than Medicare Advantage.

Medicare Advantage

Medicare Advantage plans, offered by private insurers, often bundle hospital, medical, and prescription coverage into one plan.

Many include extras like dental, vision, or gym memberships, and premiums can be lower than Original Medicare with a supplement.

However, Advantage plans typically use provider networks (HMO or PPO), which may limit your choice of doctors and hospitals.

Out-of-pocket costs can be less predictable because of deductibles, copays, and coinsurance, especially if you need specialized or out-of-network care.

There’s no one “best” option—it depends on your health, budget, and provider preferences.

Where to Get Help

• www.medicare.gov – The official Medicare website with enrollment and plan comparison tools. You can compare costs and coverage in your area for Medigap and for Medicare Advantage plans. If you set up your account and enter the drugs that you take, you can also compare the total cost of Part D insurers available to you.
• SHIP (State Health Insurance Assistance Program): Free counseling in every state.
• Generally, these services are available by calling your local senior center.
• In Massachusetts, this is called SHINE (Serving the Health Insurance Needs of Everyone).
• Your financial planner – We can help you evaluate Medicare choices in the context of your retirement income, taxes, and long-term health planning.

If you’re approaching age 65, don’t wait. Understanding when and how to enroll in Medicare—and what it will cost—can help you avoid penalties and find coverage that fits your needs.

The flowchart below is a guide that helps you determine if you’re eligible for Medicare Part A & Part B. Click on the image to download or print the chart.

-SM