Medicare Open Enrollment is underway…
Every year, between October 15 and December 7, enrollees have the opportunity to make changes to their Medicare coverage.
People can switch from original Medicare to a Medicare Advantage plan, or vice versa, enroll in Part D, or change their Part D prescription plans, and Medigap plans.
Unfortunately, for many patients (and some providers), Medicare is a mystery wrapped in paperwork and abbreviations.
The terminology, deadlines, and alphabet soup of plans (A, B, C, D) can feel overwhelming. However, understanding the coverage options and their impact on one’s healthcare is critical.
Adding to the confusion, enrollees are bombarded with aggressive advertising during open enrollment, promising low or no premiums.
Ultimately, people are left with questions like:
- “Should I switch to a free Medicare Advantage plan?”
- “I don’t take medication, so why do I need a drug plan?”
- “What is the difference between parts A, B, C, and D?”
- “Do I need to do anything during open enrollment?”
Unless these questions get clear answers, people sometimes make decisions that are not in their best long-term interest, solely to save money in the short term.
I recall a patient who enrolled in a Medicare Advantage plan to save money.
However, what she didn’t realize was that every time she had to see a specialist, her co-pay was $50 … most of her visits were to specialists.
No savings at all…
An Opportunity…
Open Enrollment is an opportunity to educate your patients about Medicare, helping them understand their options and making informed decisions about what’s best for them.
Educating your patients benefits your practice too…
It’s far easier to work with someone who understands the ins and outs of their coverage and financial obligations than to work with someone who doesn’t understand and argues about every charge.
How do you educate patients about their coverage?
Questions about coverage often come up at the front desk, as well as in the exam room.
So when the topic comes up…
1. Start with What Patients Really Want to Know
Most patients don’t want a complete lecture about Medicare; what they want to know is what applies to them. Start by asking a few basic questions:
- “Do you have Original Medicare or a Medicare Advantage plan?”
- “Do you have a prescription drug plan (Part D)?”
- “Are you happy with your current coverage and provider?”
Once you understand their current setup, you can frame information in terms they care about:
- What changes, if any, might affect their providers, prescriptions, or out-of-pocket costs?
- Whether they need to make changes to their plan before December 7.
2. Explain the Four Parts of Medicare in Plain Language
Many patients know “Medicare” but not its parts.
However, it’s essential to understand what each part of Medicare covers and how the pieces fit together before making any changes.
Medicare can be compared to a toolbox… each tool in the box serves a distinct purpose, and used together they can complete a whole project.
Each part of Medicare serves a different purpose; however, when the various parts are used together, they provide comprehensive coverage.
Part A – Hospital Insurance
Part A helps pay for inpatient hospital care, skilled nursing facility care, hospice, and some home health services.
If you paid Medicare taxes while working for at least ten years, you typically don’t pay a monthly premium.
Note: Even though Part A is premium-free for most, it’s not entirely free; budget for deductibles and potential copays.
Part B – Medical Insurance
Part B typically covers 80% of office visits, outpatient services, lab tests, preventive care, and durable medical equipment.
You’ll pay a monthly premium (automatically deducted from your Social Security payment), an annual deductible, and generally 20% of the cost for most services.
Note: Premiums for Part B can increase based on income, so check your Social Security notice each year to confirm your rate.
Part C – Medicare Advantage
Medicare Advantage plans (Part C) are offered by private insurance companies approved by Medicare.
They combine Parts A and B, often include Part D (drug coverage), and may even offer extra benefits such as dental, vision, hearing, fitness, or transportation.
These plans typically operate within networks, requiring patients to use in-network providers and hospitals (except in emergencies); often, they require a referral to see a specialist.
Note: Advantage plans may offer lower monthly costs, but they can also result in higher out-of-pocket expenses when patients need care. Always review the plan’s provider network, copays, and coverage limits before enrolling.
Part D – Prescription Drug Coverage
Part D helps pay for prescription medications.
Plans vary by cost and the specific drugs they cover, known as the “formulary”.
Note: Always review medications each fall to ensure they’re still covered at the best price under the chosen plan.
3. Emphasize That Open Enrollment Is About Review
Remind people that open enrollment doesn’t mean everyone must make changes. It’s simply an opportunity to confirm that the current coverage still fits their needs.
Encourage patients to:
- Check their current coverage
Look for notices of changes in premiums, deductibles, or covered drugs for 2026. Your current plan may have changed its drug list, network, or costs. - Compare total costs, not just premiums
A low monthly premium can be offset by higher copays or limited coverage when you need care. Compare options available using the Medicare Plan Finder. - Review their prescriptions
Ensure that medications remain covered under the plan’s formulary.
Switching plans could save hundreds of dollars a year. - Verify preferred providers, pharmacies, and hospitals
Critical if enrolled in a Medicare Advantage plan, since networks can change annually. - Factor in travel and flexibility
Traditional Medicare works nationwide, while many Advantage plans limit coverage to local networks. - Get help if necessary
Free, unbiased assistance is available through the:
– State Health Insurance Assistance Programs (SHIP) or by
– calling 1-800-MEDICARE.
Alert patients to beware of unsolicited calls or ads promising “free” Medicare upgrades. Scams targeting seniors are many and spike during open enrollment.
If the current plan still meets their needs, no action may be necessary. However, reviewing the plan annually can prevent unpleasant surprises.
4. Provide Written Handouts
Even the best verbal explanation can get lost once a patient leaves your office.
It has certainly happened to me on different occasions. Even though everything was explained to me, I couldn’t remember half of it once I was at home.
So, to reinforce your message about Medicare facts and options, keep a simple one-page handout handy (for example, “Medicare Made Simple: The Four Parts Explained”).
Handouts make the information easy to review at home, and can reduce callbacks from confused patients.
The Bottom Line
Contrary to common belief, Medicare is not a free program.
While less expensive than most commercial plans, Medicare enrollees still pay premiums, deductibles, and copays.
That’s why it’s so important to review coverage every year and make adjustments, if necessary.
Granted, Medicare open enrollment can feel like a maze.
Consequential decisions have to be made within a fixed timeline and may trigger anxiety, especially for patients with chronic conditions or limited finances.
While open enrollment is complex, reviewing their options each fall ensures patients get the coverage they need at the best cost.
Whether a patient stays with Original Medicare or switches to a Medicare Advantage plan, understanding the four parts and how they work together will increase their confidence to make informed decisions during this year’s Open Enrollment Period.
If you can empower your patients to be informed, it reinforces trust, not only with their coverage but also with your care.
How do you help your patients gain a better understanding of their Medicare coverage? Let us know in the comments below…
By Johanna Hofmann, MBA, MAc., EAMP; regular contributor to the NPBusiness blog and author of “Smart Business Planning for Clinicians.”