Medicare Open Enrollment: What to Evaluate, Resources to Help, and Common Pitfalls to Avoid
Every year between October 15 and December 7, eligible beneficiaries have the opportunity to review and revise their Medicare coverage during the open enrollment period for the upcoming year. Whether you’re newly eligible or have been on Medicare for years, this window is a critical moment to evaluate your coverage, ensure it’s aligned with your health-and-financial goals, and avoid costly mistakes.
What to Evaluate During Medicare Open Enrollment
When it’s time to revisit your Medicare options, it’s helpful to frame your review around three core questions: What coverage do I currently have? How might my needs change next year? Are there better alternatives based on costs and benefit structure?
Here are key items to evaluate:
1. Plan type and structure
Verify whether you’re enrolled in Original Medicare (Part A + Part B) and/or a Medicare Advantage plan (Part C), and whether you carry a standalone Medicare Part D (prescription drug) plan or have drug coverage via another route.
Understand what additional supplemental coverage you have (Medigap/Medicare Supplement) and whether your current plan still meets your needs.
2. Premiums, deductibles, copays and out-of-pocket maximums
The base premiums for Part B (and possibly Part A if you’re not eligible for premium-free) may change each year, as will the premiums for Advantage plans or drug plans.
Deductibles may increase; copay/coinsurance for services and drugs may shift.
For Advantage plans especially, the out-of-pocket (OOP) maximum is an important metric — some plans may offer very low premiums but higher OOP risk.
3. Network, providers and hospitals
If you're enrolled in a Medicare Advantage plan, ensure your preferred doctors/hospitals are still in-network for next year as networks can change.
If you travel frequently (seasonal residence, snowbird, etc.), check whether the plan’s network or out-of-area coverage is sufficient.
4. Prescription drug coverage
Drug formularies (the list of covered medications) may change each year. A plan you selected in the past might no longer cover one of your key medications or may shift tiers, raising your cost.
Also check whether your pharmacy is still in-network and if there are mail-order or network alternatives that might save you money.
5. Additional benefits / value add
Many Medicare Advantage plans now offer extras: dental, vision, hearing, fitness memberships, telehealth, over-the-counter allowances, or disease-management services. Review whether these fit your lifestyle and whether they deliver real value given the extra cost (if any).
If you have high medical utilization or chronic conditions, a plan with more robust coverage may make sense even if premiums are slightly higher.
6. Your health and lifestyle outlook
Ask yourself: Will my health status or medical needs change next year? Do I anticipate new medications, surgery, a lifestyle shift (travel, relocation, retirement community) that could affect which plan is best?
Align your plan choice with your financial plan: a lower-premium plan may work now, but if you’re at higher medical risk, it might make sense to accept higher premiums for greater protection.
Resources That Can Help
Selecting the right plan can feel complex. Fortunately there are resources that can make the process easier:
Medicare’s official site: The Centers for Medicare & Medicaid Services (CMS) provides the “Medicare Plan Finder” tool, allowing you to compare available plans in your ZIP code based on cost, coverage, drugs, and provider networks.
State Health Insurance Assistance Program (SHIP): Every state runs a SHIP office offering free, unbiased counseling on Medicare. They can help you understand plan changes, drug coverage, and eligibility issues.
Benefit checklists and worksheets: Create a simple spreadsheet listing your medications, preferred doctors/hospitals, anticipated health services (e.g., physical therapy, labs, specialists) and then map how each plan handles them (premium + cost share + network).
Professional support: A Medicare Insurance Agent is a licensed professional who helps clients compare and enroll in Medicare Advantage, Supplement, or Part D plans.
Employer/retiree benefit info: If you have retiree benefits, employer-sponsored health plans, or drug-coverage options via union/association, be sure to coordinate how those mesh with your Medicare choices.
Pitfalls to Avoid
Even seasoned Medicare beneficiaries can trip up during open enrollment. Here are common mistakes to watch out for:
Assuming “What I have is fine”: Because plan details can change each year (formulary changes, network shifts, premium/deductible adjustments), staying in the same plan without evaluating may cost you money or limit access.
Choosing the lowest-premium plan without factoring total cost: A plan with a very low premium may have higher copays, limited network, or weak drug coverage which can result in higher out-of-pocket costs or disrupted care.
Ignoring drug-coverage changes: One of the biggest mistakes is not verifying that your key medications remain covered, or that your pharmacy/fulfillment method remains in-network.
Failing to check provider network and service area: If your doctor leaves the network or if you move or travel frequently, you could suddenly face out-of-network costs or coverage gaps.
Overlooking supplemental coverage/coordinating benefits: If you have retiree benefits, Medicaid eligibility, employer coverage, or Medigap supplement, you need to ensure that changes in your Medicare plan don’t unintentionally reduce or disrupt other coverage.
Delaying evaluation until after December 7: Missed deadlines can mean you’re locked into your plan for the next year (unless you qualify for a special enrollment period) and might miss better options.
Letting marketing materials drive your decision: Attractive ads for “$0 premium” plans can distract from the more important metrics of network, drug coverage, total cost and how the plan fits your personal health-and-financial picture.
Your Next Step — What to Do This Week
Gather your current health-care snapshot: List your medications (with doses), preferred doctors/hospitals, recent specialists or therapies, upcoming scheduled services (e.g., surgery, therapy), travel/seasonal residence plans.
Log into the Medicare Plan Finder and/or use the SHIP counseling service: Compare your current plan with 2–3 alternatives available in your area, focusing on your specific “real-life” needs rather than general cost.
Run a cost-scenario analysis: For each plan option, estimate total expected cost = premium + expected copays/coinsurance + potential out-of-pocket maximum + any travel/rogue costs if you go out of network.
Check provider and pharmacy networks: Confirm that your doctors/hospitals and preferred pharmacy are in-network for each plan option. Pay attention to mail-order drug options if you use those.
Document your decision and inform key people: Once you’ve chosen, update your records, notify your executor/financial planner (so they know your health-care outlook), and set a reminder for the next review period.
Final Thoughts
Open enrollment for Medicare may feel routine, but making an informed choice can have significant implications for your health-care experience and your financial outcome in retirement. At Pathways Financial Planning, we believe that coverage decisions should be integrated with your broader financial plan because health-care risk, costs and lifestyle all matter when you’re building the life you envision.
