By Marilyn Marshall
If you’re one of the 66 million Americans receiving Medicare, this is a decisive time of the year for you. Open enrollment is underway, and you have until Dec. 7 to compare choices for 2025 and select the best insurance plan to suit your needs.
Medicare is the federal health insurance program for people 65 or older. You may be eligible for Medicare earlier if you have a disability, end-stage renal disease, or ALS (also called Lou Gehrig’s disease). Some people receive Medicare automatically and others must actively sign up for it, depending on if you start getting retirement or disability benefits from Social Security before you turn 65.
“The most important thing for recipients to know is that Medicare open enrollment is the period when beneficiaries already enrolled in Medicare can make changes to their health insurance,” said Shondra Wygal, associate state director of Outreach and Advocacy for AARP Texas.
“This includes reviewing options and potentially switching Medicare Advantage or Part D prescription plans to ensure they meet their health care needs for the upcoming year.”
Wygal said recipients need help understanding the types of changes they can make during open enrollment.
“To clear up confusion, they should review their options at medicare.gov or consult with a certified benefits counselor from their local Area Agency on Aging, who can offer guidance on comparing plans,” she said.
According to the U.S. Centers for Medicare & Medicaid Services (CMS), people in a Medicare health or prescription drug plan should always review the materials their plans send them, like the “Evidence of Coverage” and “Annual Notice of Change.”
“If their plans are changing, they should make sure their plans will still meet their needs for the following year,” said CMS. “If they’re satisfied that their current plans will meet their needs for next year and it’s still being offered, they don’t need to do anything.”
Medicare plans can change yearly, and your current one might be changing. Not all plans have the same benefits and out-of-pocket costs. By comparing options, you could find a plan that offers you better coverage, saves you money, or both.
Wygal said AARP assists Medicare recipients by providing resources, information, and tools to help navigate open enrollment and Medicare-related questions. They partner with organizations like the Medicare Rights Center, offer plan comparison tools, and provide access to benefits counselors through local Area Agencies on Aging, making it easier for recipients to understand and choose the right coverage.
For more information visit aarp.org/medicare
Where to go, what to ask
For help with open enrollment or other related issues, here is a list of resources from AARP Texas:
- 1-800-MEDICARE (1-800-633-4227) – Talk or live chat 24/7.
- medicare.gov – General information, including your current coverage.
- medicare.gov/prescription-payment-plan – Info on a new payment option.
- medicare.gov/care-compare/ – Find and compare providers near you.
- 1-800-252-9240 – Texas Medicare Help Line or your local Area Agency on Aging.
- shiptacenter.org or 877-839-2675 – State Health Insurance Assistance Program.
- medicarerights.org or 1-800-333-4114 – Medicare Rights Center.
Questions to ask include:
- How do I decide which Medicare plan is best for me?
- How does my Medicare plan work with other insurance?
- Will I be paying more or less for my prescriptions if I change plans?
- Are dental and vision included in the plan I am considering?
- Can I keep my same doctor if I change plans?
- What do I do if I have complaints or concerns about Medicare?
- I’m under 65 and have a disability. Am I eligible for Medicare?
- If my employer offers retiree benefits, do I need to sign up for Medicare when I turn 65?
- Am I eligible for Medicaid as well?
Medicare & health care terms to know
Copayment – A fixed amount ($20, for example) you pay for a covered health care service after you’ve paid your deductible. Copayments (sometimes called “copays”) can vary for different services within the same plan, like drugs, lab tests, and visits to specialists.
Deductible – The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself.
Donut hole – Most plans with Medicare prescription drug coverage (Part D) have a coverage gap called a “donut hole.” After you and your drug plan have spent a certain amount of money for covered drugs, you must pay all costs out-of-pocket for your prescriptions up to a yearly limit. Once you have spent up to the yearly limit, your coverage gap ends and your drug plan helps pay for covered drugs again.
Generic drugs – A prescription drug that has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs. The Food and Drug Administration (FDA) rates these drugs to be as safe and effective as brand-name drugs.
Health Maintenance Organization (HMO) – A plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won’t cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.
Inpatient care – Health care that you get when you’re admitted as an inpatient to a health care facility, like a hospital or skilled nursing facility.
Medicaid – Insurance program that provides free or low-cost health coverage to some low-income people, families and children, pregnant women, the elderly and people with disabilities. Medicaid benefits and program names vary somewhat between states.
Medicare Part A –Helps cover hospital inpatient care, skilled nursing facility care, hospice care, and home health care.
Medicare Part B – Helps cover services from doctors and other health care providers, outpatient care, home health care, durable medical equipment wheelchairs, walkers, hospital beds, and other equipment,) and many preventive services (screenings, shots or vaccines, and yearly wellness visits).
Medicare Part C (Medicare Advantage) – A plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits. If you’re enrolled in a Medicare Advantage Plan, most Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.
Medicare Part D – Helps pay for prescription drugs for people with Medicare who join a plan that includes Medicare prescription drug coverage. There are two ways to get Medicare prescription drug coverage: through a Medicare Prescription Drug Plan or a Medicare Advantage Plan.
Network – The facilities, providers, and suppliers your health insurer or plan has contracted with to provide health care services.
Original Medicare – A fee-for-service health plan that has two parts: Part A (hospital insurance) and Part B (medical insurance). After you pay a deductible, Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance and deductibles).
Preferred Provider Organization (PPO) – A plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost.
Referral – A written order from your primary care doctor for you to see a specialist or get certain medical services. In many HMOs, you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services.
Sources: medicare.gov, healthcare.gov