Medicare Open Enrollment – Two Reasons To Reassess Your Plan Each Year

Medicare Open Enrollment occurs each fall, lasting approximately seven weeks, from mid-October through early December, with coverage taking effect on January 1st. There are a number of important decisions to be made and for most people, this first time enrollment is a big event, as it should be.

Unfortunately, many older adults (and the children who help them through the process), fail to reassess their specific plans and coverage on an ongoing, annual basis. Instead, they simply allow last year’s decisions to roll over for another year.

There are two reasons why this can have negative consequences:

First, your healthcare situation may have changed.

When I help someone to enroll in Medicare, I begin by asking the following questions:

  • What medical conditions are you managing?
  • What specific medications do you take, including dosages?
  • What’s your current utilization level of the healthcare system? For example, what is your frequency of physician visits and hospitalizations?
  • What’s your anticipated use of the healthcare system? Will you be having any diagnostic testing or elective surgical procedures in the next year?
  • Where do you prefer to access your care?

Answers to these questions can then be superimposed on the Medicare options available,helping one understand how their insurance will work as they use it, as well as what the associated costs for premiums and out-of-pocket expenses will be.

But here’s the wrinkle: your situation may have changed.

For example, maybe when you initially enrolled, you were managing minimal medical conditions. Today, however, you may be planning for two, total knee replacements over the next calendar year. With that in mind, you’ll want to reassess and review the options available.

When you do, carefully consider these additional factors:

  • Your monthly premiums
  • Your deductible, if there is one (because you’ll be paying it)
  • The hospitalization benefit (because you’ll be using it). How many days are covered and at what level? Is there a daily co-insurance and, if so, for how many days?
  • The skilled nursing facility benefit, in case you need it. How many days are covered and at what level?
  • The cost for diagnostic testing and, in particular, X-Rays, CAT Scans and MRIs
  • Is a referral required? If so, you must follow the rules to receive any coverage.
  • Does a specific network need to be considered? If so, is your doctor and/or hospital in that network? If not, are there any out-of-network benefits and how much will that cover?

As you can see, upcoming health-related events can have a significant impact on the Medicare coverage you’ll need. What you had before may no longer be what is best.

Second, your healthcare plan may have changed.

Although insurance companies are required to notify you if your plan has changed in any way, I find that most people pay little attention to the written notifications they receive during the course of a year. It’s easy to ignore paperwork and think that if you don’t do anything, you’ll be re-enrolled.

That’s true. But if you don’t pay close attention, you may be quite surprised by your “new” coverage.Benefits may change and you could find yourself with out-of-pocket expenses you had not anticipated.

For example, a new client called me when she found herself paying $100.00 more for each MRI, a diagnostic test she requires fairly often to manage a medical condition. She also discovered that her co-pay for two different medications she takes regularly is now $95.00 instead of the previous $50.00. Yet another medication was no longer even covered. Lastly, she now had to pay higher out-of-pocket expenses for the hospital at which she routinely received her care (she could pay less if she switched hospitals, but that’s not what she wanted to do).

All changes that resulted from modifications to an existing plan in which she was re-enrolled.

So what should you do to guard against such changes? Here is what I suggest:

  • Revise your list of medical conditions and your comprehensive medication list.
  • Consider the care you will need in the upcoming year and identify which benefit will cover it. Investigate what the coverage level is for that benefit.
  • Check to see if your doctors and hospitals are still in the network. Be sure to ask about your specific plan and not just the company. Although a physician may take Tufts or Blue Cross, they may not take the specific Medicare Advantage Plan you have or are considering from that company.
  • Use the Medicare website. Go to Find Health and Drug Plans and enter your data. The algorithm will sort plans for which you are eligible to enroll, from the lowest cost to the most expensive. But don’t stop there; pay close attention to specific benefits and coverage levels.
  • If you are interested in a specific plan, go the company’s web site and search for the following, specific documents for that plan. Then read them carefully, keeping your individual needs in mind:
Note as well that different insurance companies may refer to these documents using slightly different labels and not every company publishes this detail online. If you can’t find what you need, call and request it.


I find insurance and Medicare to be very confusing to the average consumer. It’s even confusing tome, and I work in this area every day and have done so for many years.

Overall, be sure you pay close attention and ask lots of questions specific to YOUR needs. If you have an older individual in your life, check in with them to be sure they are adequately covered and that they understand the products in which they are enrolled. The devil is definitely in the details; time and effort spent up front will hopefully result in smooth sailing in the year ahead!