What Medicare beneficiaries need to consider during open enrollment

Medicare open enrollment kicked off on Oct. 15, with one notable difference for beneficiaries who are considering updating their health insurance plans — the federal government has been shut down since Oct. 1.

Updates related to Medicare open enrollment — which runs through Dec. 7 — will continue during the government shutdown, according to the Centers for Medicare and Medicaid Services.

Because the federal shutdown may affect timely access to information, Philip Moeller, author of “Get What’s Yours for Medicare: Maximize Your Coverage, Minimize Your Costs,” suggests holding off on finalizing coverage decisions for 2026 until the government reopens.

“I’m advising people pretty strongly to wait to make their decision about next year’s coverage,” Moeller said.

Even a change made on the last day of open enrollment will be effective starting Jan. 1, Moeller said.

“There should be no rush to make a decision,” he said.

Now through Dec. 7, Medicare beneficiaries can make changes to their coverage. Those options vary depending on your current enrollment — whether you have original Medicare, which typically includes Part A hospital insurance and Part B medical insurance, or Medicare Advantage, which are private plans approved by Medicare.

During this time, beneficiaries may switch from original Medicare to Medicare Advantage or vice versa, change Medicare Advantage plans or — provided they have original Medicare — find new Medicare Part D prescription coverage.

Medicare beneficiaries may be tempted to set-it-and-forget-it when it comes to their existing plans. But it’s wise to evaluate how much coverage may change in the coming year, particularly regarding preferred doctors or necessary medications, that could affect out-of-pocket costs, according to Juliette Cubanski, deputy director of KFF’s program on Medicare policy.

Out-of-pocket health care spending by Medicare beneficiaries represented 39% of Social Security income per person on average in 2022, recent KFF research found.

“Open enrollment offers people an opportunity to evaluate the coverage that they currently have and other options in their area to see if they might be able to get a better deal,” Cubanski said.

While some Medicare carriers are expanding in certain markets, others are pulling back or even leaving selected areas, according to Moeller. “It’s particularly important for people to do their homework this year,” he said.

The federal government shutdown may not affect Medicare open enrollment in a “big way,” according to Cubanski.

People who try to contact 1-800-Medicare for help sorting through their coverage options may experience some delays, Cubanski said.

Other resources are still open for business, like Medicare’s Plan Finder portal, Medicare Advantage or drug plans and Medigap carriers, she said.

However, the shutdown may make it more difficult to get specific answers to questions on information in the Plan Finder, Moeller said. Staffing shortages may prompt delays when using the 800 Medicare number, he said.

“Mission-critical activities and updates related to Medicare Open Enrollment will continue during the government shutdown,” states the Medicare.gov website, which is run by the Centers for Medicare and Medicaid Services. The agency did not return a request for further comment by press time on how the shutdown may impact open enrollment.

Because of those possible information constraints, Moeller said he has urged people to wait to make their decisions about next year’s coverage.

As Medicare beneficiaries consider whether to opt for original Medicare or private coverage through an Advantage plan, experts say it is worth weighing the pros and cons.

Medicare Advantage plans are typically available for no additional premium beyond the cost of a Medicare Part B premium while also providing a host of supplemental benefits, Cubanski said.

But while an Advantage plan may offer dental benefits, for example, it’s important to understand exactly what that includes, she said. Does that include just one cleaning per year, or is the coverage more extensive, such as two annual cleanings and dentures?

To be sure, Medicare Advantage typically limits access to certain services or providers, Cubanski said. Moreover, those private plans also have more prior authorization requirements that can affect access to care, she said.

On the other hand, traditional Medicare has become “increasingly unaffordable” for some beneficiaries, Cubanski said. Individuals who need a lot of medical services may face higher costs in traditional Medicare coverage, she said.

What’s more, unlike Medicare Advantage, traditional Medicare doesn’t have an out-of-pocket cap on the cost of the medical services, Cubanski said.

More information on Medicare Advantage plans is available as beneficiaries shop for plans this year, Moeller said. Medicare’s Plan Finder will include increased detail about the supplemental benefits offered by Advantage plans, such as vision, hearing and dental, he said.

Prospective Advantage enrollees will also have access to more information on doctors, hospitals and other care providers included in plan provider networks. That information will mostly be available on insurance websites, Moeller said.

The newly available information may have “some hiccups,” and beneficiaries may get the opportunity for a do-over come Medicare Advantage open enrollment, Moeller said. Medicare Advantage open enrollment lasts from Jan. 1 to March 31.

Beneficiaries covered by original Medicare plans have the option to purchase Medicare Part D to cover their prescription drugs. Those who have Medicare Advantage may find those benefits through their private plan.

Regardless, it is important to review your choices for next year to make sure your prescriptions will be covered.

“If a plan doesn’t cover all of your prescription meds, I would take it off my list,” Moeller said. “You want to make sure a plan does cover all your meds.”

More zero-premium Part D plans are available, Moeller said, which can curtail your monthly spending. However, annual deductibles for those plans are on the rise, he said. Co-pays may also move to more expensive tiers, he said.

“Don’t lose sight of the fact that it’s your overall annual costs that really should be the major basis for your decision,” Moeller said.

Notably, while more zero-premium Part D plans are available in some areas, the total number of plans overall is shrinking, Cubanski said.

The annual out-of-pocket maximum for Part D drugs will increase to $2,100 in 2026, from $2,000 in 2025. Notably, that cap only applies to prescription drugs that are covered by your plan, Cubanski said. So if you pay outside of your plan for certain treatments, that will not count towards the $2,100 out-of-pocket cap, she said.

“It always pays to shop because you just don’t know what you might be leaving on the table,” Cubanksi said. “Maybe your current plan is no longer going to offer you the best coverage at the lowest cost.”