The Biggest Medicare Problem Isn’t Choosing a Plan
Medicare coverage is about more than choosing a plan. Learn what to review each year, including doctors, prescriptions, costs, benefits, and plan changes, so you can feel confident your coverage still fits your needs.
The Biggest Medicare Problem Isn’t Choosing a Plan
When people think about Medicare, most of the attention goes toward one question: Which plan should I choose?
That’s important, but there’s another problem that doesn’t get nearly enough attention. People can have Medicare coverage and still not feel confident about how that coverage will work when they actually need it.
I call it the Medicare Coverage Confidence Gap.
Having Coverage Doesn’t Mean You Have All the Answers
You can have your Medicare card and insurance card in your wallet and still have questions. You may wonder whether your doctor is still covered, whether your prescriptions are still on the formulary, or what you would pay if you were hospitalized. You may also be unsure whether a procedure requires prior authorization or whether your copays changed for the upcoming year.
Some of the most important questions include:
Are my doctors and hospitals still in-network?
Are my prescriptions still covered?
Have my copays or deductibles changed?
Do any services require prior authorization?
Can I still use the same pharmacy?
What is changing with my plan next year?
These are the details that can make a big difference when you actually use your coverage.
Medicare Coverage Can Change
Medicare Advantage and prescription drug plans can make changes from one year to the next.
Changes may affect:
Premiums and copays
Benefits
Prescription drug coverage
Provider and pharmacy networks
Coverage rules
Each fall, Medicare plans send members an Annual Notice of Change, or ANOC. This notice explains important changes that will take effect the following January. Medicare recommends reviewing your ANOC so you can determine whether your current plan will continue to meet your needs. That doesn’t mean you need to change plans every year. It means you should know whether the coverage you already have still works for you.
The Details Matter
A Medicare Advantage plan may have a $0 monthly plan premium, but that does not mean you will pay $0 when you receive medical care.
Dental coverage does not necessarily mean every dentist participates. A prescription may be covered but still have restrictions. Your doctors, hospitals, medications and expected medical expenses all matter when deciding whether a plan continues to fit your needs.
There is no single Medicare option that is right for everyone. Instead of only asking: “Which plan has the most benefits?” A better question may be: “How well does this coverage fit the way I actually use health care?”
Prior Authorization Is One Example
Prior authorization is a good example of why understanding your coverage matters. KFF reports that 99% of Medicare Advantage enrollees are in plans that require prior authorization for at least some services. In 2024, Medicare Advantage insurers received nearly 53 million prior authorization requests and denied about 7.7% of them in whole or in part. Of the denied requests that were appealed, 80.7% were overturned in whole or in part.
Source: KFF analysis of CMS Medicare Advantage prior authorization data
Sometimes knowing what your insurance covers isn’t enough. You also need to know what to do when something doesn’t go the way you expected. That is one reason I believe having an agent you can contact after enrollment matters.
You Don’t Need to Understand Everything About Medicare
This is something I tell people often: You don’t have to understand everything about Medicare. You need to understand the things that affect you.
For most people, that means understanding:
Your doctors and hospitals
Your prescriptions
Your important copays and deductibles
What you could pay during a hospital stay
What changed for the upcoming year
Who to contact when you have a question
Trying to memorize every Medicare rule isn’t necessary. Understanding how your own coverage works is much more useful.
Your Annual Medicare Review Should Be About You
Medicare allows people to begin reviewing upcoming plan information starting October 1. Medicare’s Annual Open Enrollment Period runs from October 15 through December 7, with coverage changes generally beginning January 1.
An annual review does not automatically mean changing plans. Sometimes the answer after reviewing everything is: “Everything still looks good. Keep what you have.” Other times, something may have changed. Maybe you started taking a new prescription, began seeing a new specialist, or your plan changed its costs or benefits.
The goal of an annual review is not to find a reason to switch plans. The goal is to avoid discovering an important change after it is too late to do something about it.
Medicare Shouldn’t End With Enrollment
Choosing Medicare coverage is important, but what happens after enrollment matters too.
My clients have someone they can contact when they receive a confusing letter, have a question about a benefit, don’t understand a medical bill, need help checking a prescription, or simply want to make sure their coverage still fits.
If you would like to review your Medicare coverage for the upcoming year, I’m happy to go through the things that affect you — your doctors, prescriptions, costs and coverage.
Sometimes confirming that your current coverage still fits is the best outcome.
Sources
Medicare.gov: Annual Notice of Change and upcoming plan changes
KFF: Medicare Advantage prior authorization analysis using CMS data
Plan benefits, costs, formularies, provider networks and availability vary by plan and location and may change each year. This article is for general educational purposes.