Medicare & Medicaid

Should You Switch Medicare Plans This Enrollment Season?

Open enrollment (Oct 15–Dec 7) is when most retirees can change coverage for the year ahead: move between Original Medicare and Medicare Advantage, add or swap a Part D drug plan, or—if eligible—buy a Medigap supplement. There’s also a Medicare Advantage Open Enrollment (Jan 1–Mar 31) for people already in an MA plan to make one change. Below is a practical, situation-by-situation playbook to decide whether you should switch—or stay put.

1) “My meds got expensive or a drug was dropped.”

What to check: Your plan’s ANOC (Annual Notice of Change) and current formulary—tiers, prior authorization, step therapy, and quantity limits can change each year.
Good reasons to switch:

  • Your drug moved to a higher tier or now needs prior authorization/step therapy and another Part D (or MA-PD) covers it more generously.
  • You take high-cost meds: in 2025, Part D caps out-of-pocket spending at $2,000 for covered drugs, and you can opt to smooth payments monthly—but formularies still differ widely.
    When to stay: If your total annual cost (premium + copays) remains competitive and your pharmacy stays in-network/preferred.
    Pro tip: Price your exact medications in multiple plans each fall; the “best” plan last year often isn’t best this year.

2) “I travel a lot or split time across states (‘snowbird’).”

Consider:

  • Original Medicare + Medigap + stand-alone Part D = nationwide access to any provider that takes Medicare; Medigap can also add limited foreign travel emergency coverage on certain plans.
  • Medicare Advantage (MA) = network-based. HMOs usually won’t cover routine out-of-area care; PPOs may allow out-of-network care at higher cost. Emergencies are covered anywhere.
    Switch if: You’re frequently outside your MA plan’s service area and keep hitting out-of-network walls.
    Maybe stay on MA if: You’re a PPO user who mainly needs occasional urgent care while traveling and your core providers are in-network at “home.”

3) “I was just diagnosed with a new condition and need specialists/hospital choice.”

Original + Medigap shines for provider freedom (no referrals, any Medicare-accepting specialist) and predictable cost-sharing.
MA can still work—especially high-quality PPOs—but confirm:

  • Are the specialists and preferred hospital in-network?
  • Are key services subject to prior authorization?
    Switch if: The specialists you need aren’t in-network or approvals are causing delays.
    Caution: Moving from MA to Original + Medigap after your first 6 months on Part B may require medical underwriting in many states; you might be denied or pay more unless you have a guaranteed-issue right. Check your rights before dropping MA.

4) “I want this doctor or that surgical center.”

If that doctor/hospital accepts Medicare: Original + Medigap gives maximum flexibility.
If you prefer MA: Confirm the surgeon, facility, and anesthesiologist are all in-network for the specific plan (networks change during the year).
Switch if: Your preferred clinicians are not available in your current plan/network.

5) “I’m healthy and rarely see doctors; I want simplicity and extras.”

Why many choose MA: Often low or $0 premiums, bundled Part D, and extras (dental, hearing, vision, fitness). There’s also an annual MOOP (maximum out-of-pocket) for Part A/B services (2025 federal cap: $9,350 in-network; plans may set lower).
Stay or switch to MA if: Your providers are in-network, you value extras, and you’re comfortable with managed care rules.
Stick with Original + Medigap if: You value unlimited nationwide access and low, predictable cost-sharing—despite paying a Medigap premium and buying a separate Part D.

6) “My income dropped; costs feel heavy.”

Check help first before switching coverage type:

  • Extra Help (LIS) can lower Part D premiums and copays substantially.
  • Medicare Savings Programs (QMB/SLMB/QI) can pay your Part B premium (and more in some cases).
    Switch if: After applying for benefits, a different plan still reduces your annual cost for the same meds and doctors.

7) “My employer/retiree coverage changed.”

  • If retiree drug coverage is creditable, you may not need a separate Part D; if it’s not creditable or ends, you’ll get a Special Enrollment Period to pick Part D (or MA-PD) without penalty.
  • If a group MA plan is ending or you move out of its area, you may have guaranteed-issue rights to certain Medigap plans—valuable if you want to return to Original Medicare.

8) “My doctor left my plan’s network.”

MA networks change mid-year. If a key provider exits, call the plan for continuity-of-care options.

  • During Oct 15–Dec 7, you can choose a plan that still includes your doctor.
  • During Jan 1–Mar 31, MA enrollees get one switch (to another MA plan or back to Original + Part D).
    If frequent disruptions worry you: Consider Original + Medigap for stable access.

9) “I need major dental work.”

Original Medicare generally doesn’t cover routine dental (crowns, implants, dentures). You’d need:

  • an MA plan with robust dental benefits (read caps, networks, exclusions carefully), or
  • a separate standalone dental policy, if you stay on Original Medicare.
    Switch to MA if: A local MA plan truly covers the big dental you need and your medical providers still work for you.
    Stay with Original + Medigap if: Medical access is the priority; then add a separate dental plan and compare total costs.

10) “I’m considering switching from MA to Original + Medigap.”

Key reality check: Outside your initial 6-month Medigap window (first 6 months after Part B starts), most states allow Medigap insurers to underwrite. You might be declined or charged more unless you’re in a guaranteed-issue situation (e.g., moving out of an MA service area; certain “trial rights” after first joining MA).
Smart sequence:

  1. Confirm you can buy the Medigap policy you want before dropping MA.
  2. Line up a Part D plan.
  3. Then file the MA disenrollment during a valid window (Oct 15–Dec 7 or the MA OEP if eligible).

11) “Which path fits me? Quick portraits.”

A. The Coast-to-Coast Grandparent

  • Profile: Travels for months, sees specialists in multiple states.
  • Best fit: Original + Medigap (Plan G or N) + Part D.
  • Why: Broad access, predictable cost-sharing, limited foreign travel emergency on many Medigap plans.
  • Avoid: HMO-style MA if you’ll often be out of area for routine care.

B. The Budget-Watcher With Few Needs

  • Profile: Sees a PCP 1–2 times a year, wants basic Rx and dental cleanings.
  • Best fit: Good local MA-PD (HMO or PPO) with low premium and your doctors in-network.
  • Watch for: Prior auth rules; annual MOOP; dental annual maximums.

C. The New Cancer Patient

  • Profile: Needs NCI-center oncologist and out-of-state clinical trial consults.
  • Best fit: Original + Medigap + Part D for specialty access.
  • If currently MA: Explore switching windows and your Medigap eligibility before leaving MA.

D. The Brand-Name Biologic User

  • Profile: High-cost specialty drug every month.
  • Best fit: Any plan with best net drug cost for your exact medication and pharmacy, now with a $2,000 2025 OOP cap and an optional monthly payment plan.
  • Tip: Shop formularies every fall; differences can be thousands.

E. The Lower-Income Saver

  • Profile: Tight budget; choosing between groceries and premiums.
  • Best fit: Apply for Extra Help (Part D) and a Medicare Savings Program to reduce premiums/cost-sharing—before changing plan types.
  • Then: Pick the plan that fits your meds and doctors with the new subsidies applied.

12) Enrollment windows at a glance

  • Oct 15–Dec 7: Join, drop, or switch MA and Part D. Changes start Jan 1.
  • Jan 1–Mar 31 (MA OEP): If already in MA, make one switch (to another MA plan or to Original + stand-alone Part D).
  • Special Enrollment Periods: Moves, plan terminations, loss of creditable drug coverage, etc.
  • Medigap timing: Best time is your 6-month Medigap open enrollment after Part B starts. Outside that, switching often needs underwriting unless you have guaranteed-issue protections.

Bottom line

  • Switch if your needs changed (med list, providers, travel, diagnosis) or your 2025 ANOC shows worse costs/coverage.
  • Don’t switch just for a TV ad perk. Validate provider networks, drug tiers, prior auths, dental caps, and the MA MOOP.
  • If eyeing Medigap, test the door first. Confirm you can get the policy you want before you leave MA.
  • If money’s tight, apply for Extra Help/MSPs—they can transform your options without sacrificing care.

-Phan Trần Hương-

Sources & Further Reading