Key Takeaways

• Choosing the right Medicare plan requires more than comparing monthly premiums. You must also understand your health needs, enrollment deadlines, and how each part of Medicare affects your overall costs and coverage.

• Many people overlook critical questions that can significantly impact their access to care, prescription affordability, and total out-of-pocket expenses throughout the year.

What Are Your Current and Anticipated Health Needs?

Before selecting a Medicare plan, start by evaluating your medical needs for 2025 and beyond. Medicare coverage should align with the frequency and type of healthcare services you expect to use.

Consider these points:

• Do you visit doctors or specialists regularly?

• Are you managing chronic conditions like diabetes, hypertension, or arthritis?

• Will you need surgeries, physical therapy, or mental health services?

• Are you likely to need long-term prescription medications?

Original Medicare (Parts A and B) covers many hospital and outpatient services, but it doesn’t include prescription drugs or routine dental, vision, or hearing care. If those are essential to you, you’ll need to ask additional questions about Part D or consider Medicare Advantage plans that include extra benefits.

Have You Compared Total Costs—Not Just Premiums?

A common mistake is focusing only on the monthly premium. However, that’s just one part of your total cost.

You should also evaluate:

• Deductibles: How much do you pay before coverage kicks in?

• Copayments and Coinsurance: What do you owe for doctor visits, tests, or hospital stays?

• Out-of-Pocket Maximums: For Medicare Advantage, what’s the annual limit on spending?

• Drug Costs: If you take prescriptions, have you checked how they’re covered and tiered in a Part D or Advantage plan?

In 2025, Medicare Part D has a $2,000 cap on out-of-pocket costs for prescription drugs, which helps control expenses. But you still need to consider how fast you’ll reach that limit and whether your medications are subject to step therapy, prior authorization, or quantity limits.

Are You Comfortable With Provider Networks?

Original Medicare lets you see any doctor or specialist who accepts Medicare nationwide. That flexibility is a major benefit for people who travel or live in multiple states.

Medicare Advantage plans, on the other hand, typically have restricted provider networks. These can be HMOs or PPOs with specific rules:

• HMOs (Health Maintenance Organizations): Require referrals and limit you to in-network providers for most care.

• PPOs (Preferred Provider Organizations): Offer more flexibility but still charge more for out-of-network care.

If you already have a trusted doctor or specialist, check whether they accept Medicare or participate in the specific plan you’re considering.

Do You Need Prescription Drug Coverage—and How Good Is It?

If you’re on Original Medicare and not enrolled in a Medicare Advantage plan, you need to get a stand-alone Part D plan for prescription drugs. Not doing so when first eligible can lead to a permanent late enrollment penalty.

Before enrolling, review these factors:

• Are your current medications on the plan’s formulary?

• What tier are they listed under (generic, preferred, non-preferred)?

• Do any of your drugs require prior authorization or step therapy?

• Are your preferred pharmacies in the plan’s network?

Plans may differ in how they cover the same drugs. Even with the $2,000 out-of-pocket cap in 2025, your actual experience at the pharmacy could vary widely.

Are You Paying Attention to Enrollment Deadlines?

Missing an enrollment period can cost you more or delay your coverage. Here are the key timelines to track in 2025:

• Initial Enrollment Period (IEP): A 7-month window that starts 3 months before your 65th birthday month, includes your birthday month, and ends 3 months after.

• General Enrollment Period (GEP): January 1 to March 31 each year. If you missed IEP, you can enroll here, but your coverage begins July 1 and late penalties may apply.

• Annual Enrollment Period (AEP): October 15 to December 7. During this time, you can switch between Medicare Advantage and Original Medicare or change drug plans.

• Medicare Advantage Open Enrollment Period (MA OEP): January 1 to March 31. Only for those already in a Medicare Advantage plan—you can switch plans or go back to Original Medicare.

Stay alert to these deadlines, especially if you’re transitioning from employer coverage or moving states.

Are You Considering How Medicare Works With Other Insurance?

If you have other coverage—like through a spouse, employer, retiree plan, Medicaid, or TRICARE—you need to understand how that coverage coordinates with Medicare.

Ask:

• Will your current plan require you to enroll in Medicare at 65?

• Will it become secondary to Medicare or terminate altogether?

• Will you lose any benefits or face higher premiums by enrolling late?

Medicare often becomes the primary payer once you’re 65, even if you still have other coverage. Failing to enroll in Medicare on time can result in denied claims and late penalties.

Are You at Risk of the IRMAA Surcharge?

In 2025, if your income is above $106,000 (individuals) or $212,000 (couples filing jointly), you may be subject to the Income-Related Monthly Adjustment Amount (IRMAA). This adds a surcharge to your Part B and Part D premiums.

This surcharge is based on your 2023 tax return. If your income has recently dropped due to retirement, divorce, or other qualifying events, you can request a reassessment by filing form SSA-44.

Before choosing a plan, consider how your projected income may affect your Medicare costs—especially if you’re entering retirement this year.

Do You Understand the Differences Between Original Medicare and Medicare Advantage?

You need to understand the structural differences between Original Medicare and Medicare Advantage to make an informed decision:

Original Medicare:

• Includes Part A (hospital) and Part B (medical).

• Offers nationwide access to providers.

• Does not include drug coverage—you need a separate Part D plan.

• You may want a Medigap policy to help with out-of-pocket costs.

Medicare Advantage (Part C):

• Combines Parts A, B, and usually D in one plan.

• Often includes extra benefits like dental, vision, or hearing.

• May have limited provider networks and require prior authorizations.

• Has an annual out-of-pocket maximum, which Original Medicare lacks.

This is a major crossroads in Medicare decisions—evaluate which model aligns better with your budget, flexibility needs, and care preferences.

Have You Looked Into Medigap If You Want Original Medicare?

Medigap (Medicare Supplement Insurance) helps cover what Original Medicare doesn’t: coinsurance, copayments, and deductibles.

Important points to know in 2025:

• You’re guaranteed the right to buy a Medigap policy during your 6-month Medigap Open Enrollment Period, which starts the month you’re 65 and enrolled in Part B.

• After this period, you may be subject to medical underwriting and denied coverage based on health conditions.

• Medigap policies don’t include drug coverage—you’ll still need a separate Part D plan.

Don’t assume you can switch later without restrictions. The best time to buy a Medigap policy is when you’re first eligible.

Are You Reviewing Plan Changes Each Year?

Even if you’re happy with your current coverage, don’t ignore the Annual Notice of Change (ANOC) letter each fall. Plans can change their:

• Premiums

• Copayments

• Drug formularies

• Covered benefits

• Provider networks

Each year from October 15 to December 7, you have a chance to switch to a better plan. Don’t miss the opportunity to make sure your coverage still meets your needs for the upcoming year.

Your Medicare Decision Should Start With the Right Questions

Choosing a Medicare plan isn’t just a paperwork exercise—it’s a strategic decision that impacts your health and finances. The more questions you ask now, the fewer surprises you’ll face later.

If you’re unsure how to match your needs to the right plan, speak with a licensed agent listed on this website. They can walk you through your options and help you avoid costly mistakes.