Medicare Plan Review: When and Why to Do One

A Medicare plan review could save you hundreds or even thousands of dollars, yet most beneficiaries never do one. Whether you've had the same plan for years or you're in your first year of Medicare, reviewing your coverage annually is one of the smartest financial moves you can make.

Medicare plans change every year. Premiums increase, drug formularies shift, provider networks shrink, and your own health needs evolve. What was the perfect plan last year might be costing you money or leaving you with coverage gaps today. This guide explains when to review your Medicare coverage, what to look for, and how to determine if it's time for a change.

Why Medicare Plan Reviews Matter

Many people sign up for Medicare and never look at their coverage again. They assume if nothing's broken, there's nothing to fix. But Medicare doesn't work that way.

Plans Change Every Year

Every October, Medicare plans must file their changes for the upcoming year. These changes can significantly impact your costs and coverage:

• Premium increases: Your monthly premium can go up, sometimes substantially
• Formulary changes: Medications can move to higher cost tiers or be removed entirely
• Network changes: Doctors, hospitals, and pharmacies can leave your plan's network
• Benefit reductions: Extra benefits like dental, vision, or hearing coverage can decrease
• Cost-sharing changes: Copays, coinsurance, and deductibles can increase

Your Needs Change Too

Even if your plan stayed exactly the same, your healthcare needs don't stay static:

• New prescriptions your current plan doesn't cover well
• New health conditions requiring specialist care
• A doctor you love who's no longer in network
• Lifestyle changes like relocating or traveling more
• Financial changes affecting what you can afford

When to Do a Medicare Plan Review

While you should review your coverage every year, certain times are especially critical for a thorough plan review.

Annual Enrollment Period (October 15 - December 7)

This is the primary time to review and change your Medicare coverage. During the Annual Enrollment Period, you can:

• Switch from one Medicare Advantage plan to another
• Switch from Medicare Advantage to Original Medicare (and add a Part D plan)
• Switch from Original Medicare to Medicare Advantage
• Change your Part D prescription drug plan
• Drop Medicare Advantage and return to Original Medicare

Medicare Advantage Open Enrollment (January 1 - March 31)

If you're currently enrolled in a Medicare Advantage plan, you have one more opportunity to make changes early in the year. During this period, you can:

• Switch to a different Medicare Advantage plan
• Drop Medicare Advantage and return to Original Medicare (and enroll in a Part D plan)

Note: You cannot use this period to switch from Original Medicare to Medicare Advantage or to switch Part D plans if you have Original Medicare.

Special Enrollment Periods

Certain life events trigger a Special Enrollment Period that allows you to change plans outside the normal enrollment windows:

• Moving to a new area where your plan isn't available
• Losing employer coverage
• Your plan leaving Medicare or reducing its service area
• Qualifying for Medicaid or Extra Help
• Moving into or out of a skilled nursing facility

What to Review in Your Medicare Plan

A complete Medicare plan review should cover all aspects of your coverage. Here's a checklist of what to examine:

1. Total Annual Costs

Don't just look at the monthly premium. Calculate your true annual cost including:

• Monthly premium: What you pay each month for coverage
• Annual deductible: What you pay before coverage kicks in
• Drug costs: Your copays/coinsurance for prescriptions
• Service copays: What you pay for doctor visits, procedures, etc.
• Out-of-pocket maximum: Your maximum annual spending (Medicare Advantage only)

2. Prescription Drug Coverage

Drug coverage is often where plan differences matter most. Review:

• Formulary coverage: Are all your medications covered?
• Tier placement: What tier is each drug on (determines your copay)?
• Prior authorization: Do any medications require approval before coverage?
• Quantity limits: Are there restrictions on how much you can get?
• Pharmacy network: Is your preferred pharmacy in network?

3. Provider Network

If you have Medicare Advantage, your doctors must be in network for coverage. Check:

• Is your primary care doctor still in network?
• Are your specialists in network?
• Is your preferred hospital in network?
• If you travel, what's the out-of-area coverage?

4. Extra Benefits

Medicare Advantage plans often include extras beyond Original Medicare. Review any changes to:

• Dental coverage (routine vs. comprehensive)
• Vision coverage (exams, glasses, contacts)
• Hearing coverage (exams, hearing aids)
• Fitness benefits (gym memberships, SilverSneakers)
• Over-the-counter allowances
• Transportation to medical appointments

5. Plan Quality Ratings

Medicare rates plans on a 1-5 star scale based on quality and customer satisfaction. Plans with higher ratings often have:

• Better customer service
• Fewer prior authorization hassles
• More accurate claims processing
• Better health outcomes for members

Red Flags That Mean It's Time to Switch

During your review, watch for these warning signs that your current plan may no longer be the right fit:

Significant Premium Increase

Some premium increases are normal, but if your premium jumps significantly (more than 10-15%), it's worth shopping around. Other plans may not have increased as much.

Your Medication Isn't Covered

If a drug you take regularly is removed from the formulary or moved to a non-preferred tier, you could face much higher costs or need to switch medications. Consider plans that cover your prescriptions better.

Your Doctor Left the Network

If your primary care doctor or an important specialist is no longer in network, you'll either pay significantly more to see them or need to find new providers. A different plan might include your preferred doctors.

Star Rating Dropped

If your plan's star rating decreased, it may indicate declining quality. Members often experience more prior authorization denials, longer wait times, and poorer customer service with lower-rated plans.

You're Paying for Benefits You Don't Use

If you're paying a higher premium for extra benefits like comprehensive dental but never use them, you might save money with a simpler, lower-premium plan.

How to Do Your Medicare Plan Review

Here's a step-by-step process for conducting a thorough Medicare plan review:

Step 1: Gather Your Information

Before you start comparing plans, collect:

• List of all your current medications (name, dosage, frequency)
• Names of your doctors, specialists, and preferred hospital
• Your preferred pharmacy
• Your current plan's Annual Notice of Change (arrives by September 30)
• Any anticipated healthcare needs for the coming year

Step 2: Use the Medicare Plan Finder

Go to Medicare.gov/plan-compare and enter:

• Your zip code
• Your medications
• Your pharmacy preference
• Your doctor preferences (if applicable)

The tool will estimate your total annual costs for each available plan based on your specific medications and needs.

Step 3: Compare Estimated Annual Costs

Don't just compare premiums. Look at the total estimated annual cost, which includes:

• Annual premium (monthly premium x 12)
• Drug costs based on your prescriptions
• Estimated costs for services you regularly use

Step 4: Verify Network Coverage

For any Medicare Advantage plans you're considering, go to the plan's website or call to verify:

• Your doctors are in network
• Your preferred hospital is in network
• Your pharmacy is in network (especially for preferred pricing)

Step 5: Consider Your Health Trajectory

Think about the year ahead:

• Are you planning any procedures or surgeries?
• Has your doctor mentioned new treatments you might need?
• Do you have a chronic condition that may require more care?
• Are you generally healthy and expecting minimal healthcare use?

Should You Review Switching Between Original Medicare and Medicare Advantage?

Your annual review is also a good time to consider whether you're on the right path altogether. Here's when to consider switching:

Consider Switching to Original Medicare + Medigap If:

• You want freedom to see any doctor who accepts Medicare
• You travel frequently or live in multiple locations
• You've had prior authorization issues with Medicare Advantage
• You have chronic conditions requiring frequent specialist care
• You can afford Medigap premiums for predictable costs

Consider Switching to Medicare Advantage If:

• You want lower monthly premiums
• You value extra benefits like dental and vision
• You don't mind using a network of providers
• You're comfortable with prior authorization requirements
• The out-of-pocket maximum provides financial security

For a detailed comparison, see our guide on Medigap vs. Medicare Advantage.

Getting Help with Your Medicare Plan Review

You don't have to do your Medicare plan review alone. Several resources can help:

Free Help

• State Health Insurance Assistance Program (SHIP): Free, unbiased counseling in every state
• 1-800-MEDICARE (1-800-633-4227): Official Medicare helpline
• Medicare.gov Plan Finder: Online comparison tool

Fee-Only Medicare Advisors

If you want personalized guidance without sales pressure, consider a fee-only Medicare advisor. Unlike insurance agents who earn commissions, fee-only advisors work for you and have no financial incentive to recommend one plan over another.

A fee-only advisor can:

• Review your complete Medicare situation
• Compare all available options in your area
• Explain the trade-offs in terms specific to your needs
• Help you understand complex rules and deadlines
• Provide ongoing support throughout the year

Your Medicare Plan Review Action Plan

Here's a simple checklist to ensure you complete your Medicare plan review each year:

1. September: Watch for your Annual Notice of Change in the mail
2. October 1-14: Review the ANOC and note any changes
3. October 15: Use Medicare Plan Finder to compare options
4. October-November: Verify networks and talk to advisors if needed
5. By December 7: Enroll in your chosen plan (or stay with current if it's still best)
6. January: Verify new coverage is active and ID cards received