My Health Changed: What to Do with Your Medicare Coverage

Our health care needs will change throughout our lives – it’s that simple. Pre-existing or new conditions may evolve resulting in going to your primary care doctor or specialists more frequently or requiring new health coverage benefits. 

If you find yourself saying, “my health has changed,” then it’s time to take inventory of your Medicare coverage. Below we offer some tips on how to evaluate your current Medicare coverage, decide if you need to make any changes and how to make those changes if required. 

How to Evaluate Your Medicare Coverage	Jump to
When Can I Change My Coverage?	Jump to

How to Evaluate Your Medicare Coverage

As our health needs change, so should your Medicare coverage. Depending on which form of Medicare you have – Original Medicare or a Medicare Advantage Plan – will determine if you need to switch plans, add a supplemental plan or change to another type of coverage. 

The two biggest questions you need to ask yourself are: 

• How much are your out-of-pocket costs?  
• Are there any gaps in your coverage?

If you have Original Medicare

Original Medicare is the health insurance offered by the United States government, consisting of Medicare Part A (hospital insurance) and Medicare Part B (medical insurance). Original Medicare doesn’t include prescription drug coverage. Those who need drug coverage have to get a stand-alone Prescription Drug Plan (Medicare Part D).

How much are your out-of-pocket costs?
A defining characteristic of Original Medicare is how much you pay in out-of-pocket costs. You’ll still pay 20% of the Medicare-approved amount for coinsurance for your Medicare Part B-covered services after you meet your deductible. There isn’t a yearly limit on what you pay out of pocket.  

These out-of-pocket costs can quickly add up if you need to visit the doctor frequently. If you’re worried about the cost of your coverage, then you may want to consider switching to a Medicare Advantage Plan that includes a yearly limit on out-of-pocket expenses or adding a Medicare Supplement Insurance Plan that may help cover copays, coinsurance and deductibles.

Are there any gaps in my coverage?
Original Medicare covers most medically necessary services. However, there are some obvious gaps in coverage, including:

• Prescription Drugs 
• Vision 
• Dental  
• Hearing 
• Over-the-Counter Benefits 
• Appointment Transportation 

If you find yourself wanting coverage that’s not typically found in Original Medicare, you may consider switching to a Medicare Advantage Plan with the benefits you want.

If you have a Medicare Advantage Plan

Medicare Advantage Plans are known as “all-in-one” private insurance plans that include Original Medicare,
usually prescription drug coverage and other extra benefits. 

How much are your out-of-pocket costs?
Unlike Original Medicare, which doesn’t have a yearly out-of-pocket limit and requires you to pay a 20% coinsurance after you hit your deductible, Medicare Advantage Plans have built-in protections to keep costs lower.
Medicare Advantage Plans may have lower out-of-pocket costs for certain services and yearly limits on what you pay for out-of-pocket services.  

If you still feel like you’re paying too much in out-of-pocket expenses, then you may want to consider switching to another Medicare Advantage Plan that fits your budget.

Are there any gaps in my coverage?
If you believe your current plan is missing some coverage, then it may be time to consider switching to a plan that offers the coverage you need. For example, while most Medicare Advantage Plans come with prescription drug coverage, some don’t.  

Outside of benefits, you should consider if you’re seeing the right doctors or specialists and if they’re in your network. Unlike Original Medicare – which allows you to see any doctor that accepts Medicare – Medicare Advantage Plan enrollees must see doctors within the plan’s network.

When Can I Change My Coverage?

People with Medicare will have access to different enrollment periods throughout the year, which happen annually or during special life events.

Medicare Annual Enrollment Period
The Medicare Annual Enrollment Period (AEP) happens each year from Oct. 15 to Dec. 7. It is available to all Medicare enrollees. During this time, you can:

• Switch from Original Medicare to a Medicare Advantage Plan 
• Add, switch or remove Prescription Drug Coverage (MA or Original Medicare) 
• Switch from an MA Plan to another MA Plan 
• Drop an MA Plan for Original Medicare 
• Add a Medicare Supplement Insurance plan to Original Medicare 
• Switch to a different Medicare Supplement Insurance plan 

Once you make a change, it’ll go into effect on Jan. 1 of the following year.

Medicare Advantage Open Enrollment Period
The Medicare Advantage Open Enrollment Period (OEP) happens annually from Jan. 1 to March 31 and is available to MA Plan enrollees wanting to change to their plan. This period is more restrictive on what you can and can’t do. During OEP, MA enrollees can: 

• Switch from an MA Plan to Another MA Plan or carrier 
• Switch to or from an MA Plan with Prescription Drug Coverage 
• Revert from an MA Plan to Original Medicare and join a Prescription Drug Plan and/or a Medicare Supplement Insurance plan^* 

^* Medicare Supplement Insurance enrollment may be subject to underwriting. 

If you have Original Medicare and want to switch to Medicare Advantage or add prescription drug coverage to your Original Medicare, then you’ll be ineligible to make a change using this enrollment period.

Special Enrollment Periods
There are times when you can make changes to your Medicare plan outside of the annual enrollment periods.
These times are called Special Enrollment Periods (SEPs) and are triggered by certain life events.  

These life events include, but are not limited to:

• Moving to a new address outside your plan’s service area 
• Losing your current coverage 
• Your plan changes its contract with Medicare 
• You’re now eligible for both Medicare and Medicaid 

If you’re eligible for a SEP or not sure if you qualify, you can speak to a licensed insurance agent to find out.

Education is crucial in finding the right Medicare solution for you. With so many Medicare resources out there, it can be difficult finding a source you can trust. That’s why Ensurem has a Compliance Program dedicated to ensuring our Medicare content meets CMS regulations. So, you can rest assured you’re getting the information you need to make the right coverage decisions. Learn more here.