Your cards are in the mail or in your wallet. This guide walks through everything that comes next, in the order it actually happens. Original Medicare and Medicare Advantage are both covered. Where the two paths diverge, it is labeled clearly.
Topic one
Your cards arrived
Three pieces of mail arrived, or are about to. Understanding what each one is, what it does, and what to do with it right now is the first practical step in Medicare.
Original Medicare
From Social Security / CMS
Medicare card
Red, white, and blue
Shows your Medicare number, name, and the date Part A and Part B began. This is your proof of Medicare coverage. Bring it to every medical appointment alongside your Medigap card.
Guard the Medicare number like a Social Security number. It is used for identity theft. Call 1-800-MEDICARE if it is lost or stolen.
From your Medigap insurer
Medigap card
Supplement insurance card
Shows your plan letter (G, N, etc.), member ID, and the insurer's billing number. Carry this alongside your Medicare card. Providers need both to process a claim correctly and send the remainder to your Medigap plan automatically.
Verify the plan letter matches what you enrolled in. If it has not arrived within 30 days of enrollment, call the insurer directly.
From your Part D plan
Drug plan card
Part D prescription card
Shows your plan name, member ID, group number, and the Rx BIN and PCN numbers your pharmacy needs. Bring this to the pharmacy, not your Medicare card. Your Medicare card is not used for prescriptions.
Take this to your pharmacy before your next prescription is due. Ask them to run a test claim on all your current medications so you know what each will cost before you need them.
Medicare Advantage
From your Advantage plan
Medicare Advantage card
Replaces Original Medicare for most visits
This is the card you show at every appointment. It replaces your red, white, and blue Medicare card for most provider interactions. Drug coverage is usually on this card or a second card from the same plan.
Call your plan to confirm whether drug coverage is on this card or a separate one. Verify your primary care doctor is still in-network before your first appointment.
Keep it, do not use it day-to-day
Original Medicare card
Still valid, rarely used
You keep your red, white, and blue Medicare card even on Medicare Advantage. Most providers will not use it while your Advantage plan is active. You may need it if your Advantage plan ends or if you need emergency care while traveling out of your plan's service area.
Store it somewhere safe. Do not throw it away.
Set up your Medicare account at medicare.gov now, before you need it.
Create a free account at medicare.gov. You can view all your claims in real time, check coverage status, and see exactly what Medicare has been billed in your name. Claims appear within days of processing. Doing this now means you already know how to use it when something looks wrong on a bill.
Topic two
What your coverage does not pay for
Medicare is good coverage. It is not complete coverage. Knowing the gaps before you need care is what lets you plan for them. Most people discover these gaps at the worst possible moment - when a bill arrives that they did not expect. You are reading this now so that does not happen to you.
Original Medicare
Gaps in Original Medicare
The 20% with no cap
Part B covers 80% of outpatient services. You owe the remaining 20% with no annual out-of-pocket maximum. A $100,000 outpatient surgery leaves you with $20,000 owed. A $500,000 event leaves $100,000. There is no ceiling on your exposure under Original Medicare alone.
Medigap fills this
Part A hospital deductible
$1,676 per benefit period in 2025. Not per year - per benefit period. Two hospitalizations in one year can mean paying this deductible twice if a new benefit period starts. There is no limit on the number of benefit periods per year.
Medigap Plan G fills this
Skilled nursing facility days 21 through 100
Days 1 through 20 in a skilled nursing facility are fully covered after a qualifying hospital stay. Days 21 through 100 cost $209.50 per day in 2025, totaling up to $16,760. Day 101 and beyond are not covered at all.
Medigap Plan G fills this
Dental
Routine dental care - cleanings, fillings, crowns, extractions, dentures - is not covered. The exclusion has been in the Medicare statute since 1965. Medicare covers dental only when it is part of a covered medical procedure, such as jaw reconstruction after an accident.
Standalone dental plan
Hearing aids
Hearing aids and routine hearing exams are not covered. The exclusion is written into the Medicare statute. Diagnostic hearing evaluations ordered by a physician for a medical condition are covered under Part B. Over-the-counter hearing aids for mild to moderate loss became available in 2022 at pharmacies for $200 to $1,500.
OTC aids or standalone plan
Routine vision and glasses
Routine eye exams for prescriptions and eyeglasses are not covered. Medical eye conditions - cataracts, glaucoma, macular degeneration, diabetic retinopathy - are covered under Part B. One pair of standard glasses after cataract surgery is covered. That is the full extent of Medicare vision coverage.
Standalone vision plan
Custodial care - daily help at home
Help with bathing, dressing, eating, toileting, and moving around is not covered by Medicare even when medically necessary. Medicare covers skilled care only - nursing, therapy, and medical monitoring. When the skilled need ends, coverage ends. Someone who needs daily help but no skilled care gets nothing from Medicare.
Medicaid or private pay
Long-term care
Ongoing care in a nursing home, assisted living, or memory care unit is not covered beyond the 100-day skilled nursing benefit. The average woman needs 3.7 years of long-term care in her lifetime. The average man needs 2.2 years. Neither Medicare nor Medigap covers any of it once the skilled care period ends.
LTC insurance or Medicaid
If you enrolled in Medigap during your six-month open enrollment window, you are protected from the 20% gap. If you did not, this is urgent.
The Medigap open enrollment window opens the month you are both 65 and enrolled in Part B. During this window, no insurer can deny you or charge more based on your health. After it closes, in most states they can - and will, if you have any health history. If your window is still open, enrolling in Medigap is one of the most financially important things you can do. If it has already closed, see the options below.
A small number of states require Medigap insurers to accept applications year-round regardless of health history. Connecticut, Maine, Massachusetts, New York, and a few others fall into this category. If you live in one of these states, the window effectively never closes.
In most states, your options after the initial window are more limited. You can apply and an insurer may accept you if your health history is minimal. You can wait for a qualifying event that triggers a new guaranteed issue right - for example, if your Medicare Advantage plan leaves your service area, you gain a right to certain Medigap plans without medical underwriting. A SHIP counselor can identify which qualifying events apply in your state.
If Medigap is not available or affordable, Medicare Advantage is the realistic alternative. It has an out-of-pocket maximum, which Original Medicare lacks, but comes with network restrictions and prior authorization requirements. Switching from Original Medicare to Medicare Advantage can be done during Open Enrollment each October 15 through December 7.
Medicare Advantage
Gaps in Medicare Advantage
Network restrictions
Out-of-network providers are either not covered or significantly more expensive. Your current doctors may not be in-network. A doctor in-network this year may leave the network next year. Emergency care anywhere is covered at in-network rates, but everything else is subject to your plan's network.
No standard fix
Prior authorization
Many services - specialist visits under HMO plans, some hospitalizations, imaging, equipment, and certain procedures - require advance approval from the plan. Approval can be denied. You have appeal rights but the process takes time and care can be delayed in the meantime.
Appeal rights exist
Annual plan changes
Your plan's network, drug formulary, premiums, and covered benefits can change every October for the following year. A plan that fit you this year may not fit next year. This requires active review every fall. Many people discover their plan changed only when they encounter a problem mid-year.
Review every October
Out-of-pocket maximum is high
Medicare Advantage plans must have an out-of-pocket maximum, which Original Medicare lacks. However, that maximum can be $9,350 or more per year in 2025. A serious illness can push your costs close to that cap before the protection kicks in.
Cap exists but is high
No Medigap option
You cannot have both Medicare Advantage and Medigap. If you switch back to Original Medicare later, in most states the Medigap insurer can review your health history and deny your application or charge higher premiums. The guaranteed issue right from age 65 does not automatically return.
Timing matters
Dental, vision, and hearing - verify what is actually covered
Many Advantage plans advertise dental, vision, and hearing benefits. These are not standardized. "Dental coverage" can mean cleanings only or full restorative care. The only way to know is to read your Evidence of Coverage document - the full plan contract sent when you enrolled. Do not assume a benefit applies based on a marketing summary.
Check Evidence of Coverage
Custodial and long-term care
Same gap as Original Medicare. Medicare Advantage does not cover custodial care or long-term care beyond the skilled nursing benefit. Some plans include modest home support benefits, but these are not a substitute for full custodial coverage.
Medicaid or private pay
Topic three
Before your first appointment
Getting your coverage set up correctly before you need it prevents almost every billing problem new Medicare enrollees encounter. These steps take less than an afternoon and protect you from months of confusion later.
1
Call every current doctor and give them your new insurance information
Every provider you currently see needs to know your Medicare coverage started and what your new insurance information is before they submit any claims or refill any prescriptions. If they bill the wrong plan, the claim gets rejected, the billing process restarts, and you receive confusing paperwork in the mail. Do this before your next scheduled appointment or prescription refill, not after it.
2
Go to your pharmacy with your new drug card before your next refill
Give the pharmacy your Part D card and ask them to run a test claim for every medication you currently take. This confirms which drugs are covered, at what tier, and at what cost before you are at the counter needing a prescription filled. If a drug is not covered or is on a higher cost tier than expected, your pharmacist can check for covered alternatives or help you start a formulary exception request with your plan.
3
Handle dental, vision, and hearing needs now if you have them
If you had dental, vision, or hearing coverage under a previous employer plan or Marketplace plan, that coverage is ending. Medicare covers almost none of these. If you have a dental procedure you have been delaying, an eyeglass prescription due, or a hearing evaluation needed, address those before your old coverage ends. After Medicare starts, you need a separate standalone plan for each, and most dental plans have waiting periods of 6 to 12 months before they cover major services. Act now, not after the gap.
4
If you have Medicare Advantage: verify every current doctor is in-network before scheduling anything
Do not assume your current doctors are in your plan's network. Call each office directly and ask whether they are currently in-network for your specific plan by name - not "do you take Medicare" or even "do you take Medicare Advantage," but the actual plan name printed on your card. Online directories are often months out of date. An out-of-network visit on an HMO plan can mean paying the full cost of the visit yourself. Confirming with the office directly is the only reliable check.
5
Read your Evidence of Coverage document if you have Medicare Advantage
Your plan mailed you an Evidence of Coverage document when you enrolled. This is the actual contract between you and the plan. It tells you what requires prior authorization, how referrals work if you have an HMO, what your out-of-pocket maximum is, and what your dental and vision benefits actually include. Most people never read it and encounter its contents only when a claim is denied. Read the prior authorization, referral, and covered benefits sections before your first appointment.
A SHIP counselor will do all of this with you for free.
The State Health Insurance Assistance Program has trained counselors in every state who help new Medicare enrollees set up their coverage correctly. They do not sell insurance and have no financial interest in your decisions. Find your local SHIP at shiphelp.org.
Topic four
Setting up your care
Finding a primary care doctor on Medicare is not the same as finding one on employer insurance. The rules are completely different depending on which type of Medicare you have, and getting this wrong early creates problems that take months to untangle.
Original Medicare
1
You can see any doctor in the country who accepts Medicare - no referrals required
Original Medicare has no network. You are not restricted to a list of approved providers. You can see any doctor, anywhere in the country, who accepts Medicare patients. You do not need a referral to see a specialist. This is one of Original Medicare's most significant advantages and it is frequently misunderstood by people accustomed to employer insurance where networks and referrals were standard.
2
Confirm the doctor accepts Medicare assignment - not just Medicare
There is a difference between a doctor who "takes Medicare" and one who "accepts Medicare assignment." Accepting assignment means the doctor agrees to accept Medicare's approved amount as full payment and will not charge you more than your standard 20% cost share. A doctor who does not accept assignment can charge up to 15% above Medicare's approved rate - which you owe on top of your 20%. Verify assignment at medicare.gov/care-compare or ask the office directly.
3
Ask whether the doctor is accepting new patients before you schedule
A doctor who accepts Medicare may still have a closed panel - meaning they are not taking new patients regardless of insurance. Ask when you first call, before any scheduling attempt. In areas with primary care shortages, closed panels are common. If your preferred doctor is not accepting new patients, ask about their waitlist or ask a SHIP counselor for alternatives who accept Medicare assignment in your area.
Medicare Advantage
1
Know whether your plan is an HMO or a PPO - the rules are completely different
HMO plans require you to choose a primary care provider and get referrals before seeing most specialists. You generally cannot see out-of-network providers. PPO plans let you see specialists without a referral and allow out-of-network visits, though at higher cost. If you are not certain which type you have, call the plan's member services line or check your Evidence of Coverage. The plan type is not always printed on your card.
2
Verify every current doctor by your specific plan name, not just by phone
Call each doctor's office and ask: "Are you currently in-network for [your plan name]?" Not "do you take Medicare Advantage" - your specific plan name. Networks are renegotiated annually and online directories can lag several months behind. The office billing staff will know their actual current network participation in real time.
3
Understand emergency care outside your network
Emergency care is covered by Medicare Advantage at in-network rates regardless of where you are. If you need emergency care at any emergency room in the country, your plan must cover it. The emergency exception applies to genuine emergencies - conditions a reasonable person would believe require immediate care. Non-emergency urgent care outside your network is handled differently and verifying your plan's specific policy before you need it.
Establish care with a primary doctor before you need one urgently.
The worst time to find a new primary care doctor is when you are sick. Establishing care early - even with just a wellness visit - means a provider knows your history when something happens. It also activates your Annual Wellness Visit benefit, which is free under Medicare, and creates the continuity of care that becomes critical in Stage 3 of this journey.
Topic five
Using your coverage for the first time
The first time you use Medicare - whether it is a prescription, a piece of equipment, a referral, or a routine visit - the same basic process applies. Understanding how a claim moves from the moment something is ordered to the moment you receive a bill is what makes every other step in this guide make sense.
How a Medicare claim works
Your doctor orders something
A prescription, a referral, an imaging order, a piece of equipment, a lab test. The physician order is the trigger. Nothing is billed until a licensed provider has ordered it.
The provider submits a claim to Medicare
Your doctor, pharmacy, equipment supplier, or lab submits a claim to Medicare directly. You do not submit claims yourself. For Medicare Advantage, the provider submits to your plan instead of directly to Medicare.
Original Medicare
Medicare pays 80% of the approved amount
Medicare reviews the claim and pays its approved rate - typically 80% for Part B services. The remaining 20% is your responsibility, or your Medigap plan's responsibility if you have one.
If you have Medigap
Medigap pays its share automatically - no action needed from you
After Medicare pays, it sends the claim directly to your Medigap insurer through a process called crossover billing. Your Medigap plan pays its share based on your plan letter. You do not file a separate claim. With a Plan G, your remaining cost is typically zero for Part B services.
The provider sends you a bill for the remainder
After Medicare and any secondary coverage has paid, the provider bills you for whatever is left. If you have a Medigap Plan G and the service is Medicare-covered, the remainder is typically zero or just your Part B deductible for the year.
Medicare Advantage claims work differently - and prior authorization adds a step before you receive care.
Your Advantage plan processes all claims internally. For many services - specialist visits on HMO plans, some hospitalizations, imaging, and equipment - the plan must approve the service before you receive it. If your doctor orders something that requires prior authorization, the doctor's office submits the request. Always ask the doctor's office whether a service needs prior authorization before scheduling, so you are not surprised by a denial after the fact.
When you fill a prescription, the pharmacy submits a claim to your Part D plan directly. Your cost at the counter is your plan's cost-sharing for that drug's tier. Tier 1 generics typically cost $0 to $10. Tier 4 and 5 specialty drugs can cost significantly more, though the 2025 Part D out-of-pocket cap of $2,000 per year limits your total annual drug cost for covered medications.
If a drug is not on your plan's formulary, the pharmacy will tell you. Do not pay out of pocket on the spot. Ask your pharmacist about covered alternatives, or ask about a formulary exception - a formal request for coverage of a non-formulary drug based on medical necessity. Your doctor's office typically initiates this request.
For Medicare Advantage with bundled drug coverage, use your plan card at the pharmacy, not your Original Medicare card. The drug benefit flows through your Advantage plan, not through a separate Part D claim.
Durable medical equipment - walkers, canes, wheelchairs, CPAP machines, home oxygen, hospital beds, blood glucose monitors - is covered under Medicare Part B when ordered by a physician and deemed medically necessary. You pay 20% of the Medicare-approved amount after the Part B deductible, or nothing if you have a Medigap plan that covers Part B coinsurance.
The supplier must be enrolled in Medicare. For Original Medicare, you can use any Medicare-enrolled supplier. For Medicare Advantage, you must use an in-network supplier or pay the full out-of-network cost.
Power wheelchairs and some other equipment categories require prior authorization under both Original Medicare and most Advantage plans. Your doctor must document medical necessity and the claim goes through review before equipment is approved. Ask your doctor's office to confirm authorization status before the supplier delivers anything.
Original Medicare: No referral required. You can schedule directly with any specialist who accepts Medicare. You do not need your primary care doctor's approval. This is one of the clearest practical advantages over Medicare Advantage HMO plans.
Medicare Advantage HMO: A referral from your designated primary care provider is typically required before seeing most specialists. Your PCP submits the referral to the plan for authorization. Seeing a specialist without an approved referral on an HMO plan generally means you pay the full cost yourself.
Medicare Advantage PPO: You can self-refer to specialists. Out-of-network specialists are allowed but cost more. No referral is required, but network status significantly affects your out-of-pocket cost.
Topic six
Your first bill
Three types of documents arrive after you receive care. Two of them look like bills. Only one actually is. Paying the wrong one too early is one of the most common and easily preventable financial mistakes new Medicare enrollees make.
Original Medicare
From Medicare - quarterly
Medicare Summary Notice
MSN - not a bill
A statement showing every service billed to your Medicare number in the past three months. Shows what was billed, what Medicare approved, what Medicare paid, and what you may owe. Arrives even if no claims were processed that quarter.
Do not pay this. Review it for services you did not receive. Any service that appears that you did not receive should be reported to 1-800-MEDICARE immediately - that is Medicare fraud.
From your Medigap plan - per claim
Explanation of Benefits
EOB - not a bill
Your Medigap insurer sends this after each claim. Shows what Medicare paid, what your Medigap plan paid, and what if anything remains. It is a record of how the claim was processed, not a request for payment from you.
Do not pay this. Use it to verify the provider bill matches what this document says you owe. If they differ, call the provider before paying.
From your doctor or hospital
Provider bill
This one you pay
The actual request for payment. Shows the service, what Medicare and Medigap paid, and the remaining balance owed by you. This is the only one of the three documents that is a bill.
Wait for your MSN and EOB before paying. The balance on this bill should match what those two documents show you owe. If it does not, call the provider's billing department before writing a check.
Never pay a provider bill before your Medicare Summary Notice arrives.
Medicare and your secondary coverage need time to process the claim and pay their shares. The provider bill that arrives first shows the full charge before insurance has paid anything. Paying it immediately often means overpaying. Most providers give you 30 to 90 days before a bill is overdue. Use that window to wait for your MSN and EOB, then compare all three documents before paying.
Medicare Advantage
From your Advantage plan - per claim
Explanation of Benefits
EOB - not a bill
Your Medicare Advantage plan sends this after each claim. Shows what was billed, what the plan paid, and your cost-sharing responsibility. There is no separate Medicare Summary Notice for Advantage - your plan processes claims internally and this document is its equivalent.
Review it. Do not pay it. Compare it to the provider bill when that arrives. Track your running cost-sharing total against your plan's out-of-pocket maximum.
From your doctor or hospital
Provider bill
This one you pay
The request for payment showing your cost-sharing after the plan has paid. The amount should reflect your plan's copay or coinsurance for that service type. Once you reach your annual out-of-pocket maximum, your cost-sharing stops for the rest of the year.
Compare to your EOB. If the amounts differ, call your plan before paying anything. Note your cumulative out-of-pocket spending toward your plan's annual maximum.
Provider bill is higher than your MSN or EOB says you owe: Call the provider's billing department with both documents in hand. Ask them to reconcile the discrepancy. Do not pay the higher amount until they can explain it. Billing errors are common and most resolve with a single phone call.
A service on your MSN that you never received: This is Medicare fraud. Call 1-800-MEDICARE (1-800-633-4227) immediately or report at medicare.gov. Fraud on your Medicare account affects your coverage record, so report it promptly even if the dollar amount is small.
Your Medicare Advantage plan denied a claim: You have the right to appeal. Your plan must tell you why the claim was denied and how to appeal. The first level goes to the plan itself. If denied again, it escalates to Medicare's Independent Review Entity. A SHIP counselor can walk you through the appeal process at no charge.
A bill you cannot pay: Call the provider's billing department and ask about a payment plan or financial assistance. Hospitals that receive Medicare or Medicaid funding are required to have charity care policies. Ask about financial assistance before the bill goes to collections - it is significantly harder to resolve after that point.
Topic seven
What costs you nothing
Medicare covers a broad set of preventive services at no cost - no deductible, no copay. Most people skip these services because they assume there will be a charge. There will not be, as long as the visit is billed correctly and you know how to ask for it by name.
Annual Wellness Visit
Yearly visit to develop or update your preventive care plan. Covers health risk assessment, medication review, cognitive screening, and referrals. Not a physical exam - billing it as one generates a charge.
Once per year
Welcome to Medicare visit
A one-time preventive visit in your first 12 months of Part B. Reviews your health history, identifies risk factors, provides education and referrals. Available once only.
Once, first year only
Cancer screenings
Mammograms, colorectal screenings (colonoscopy, stool tests), cervical cancer, lung cancer CT for qualifying smokers, prostate screenings. Frequency and eligibility vary by type and risk.
Schedule varies by type
Cardiovascular screenings
Cholesterol, lipids, and triglycerides every five years. Abdominal aortic aneurysm screening once for men who have smoked. Cardiovascular behavioral therapy counseling visits.
Every 5 years or once
Diabetes screenings
Up to two blood sugar tests per year for those at risk. Diabetes self-management training if you have diabetes. Hemoglobin A1c testing for people with diabetes.
Up to twice yearly
Depression screening
Annual depression screening in a primary care setting. No cost sharing when billed correctly as a preventive service.
Once per year
Bone density testing
Every two years for women at risk for osteoporosis and others who qualify. Screens for bone loss before a fracture occurs.
Every 2 years
Vaccines
Flu (annual), pneumococcal, COVID-19, hepatitis B, and RSV are covered under Part B with no cost sharing. Shingrix (shingles vaccine) is covered under Part D - use your drug card, not your Medicare card, at the pharmacy.
Annual and one-time
The Annual Wellness Visit is not the same as an annual physical. The difference shows up on your bill.
Original Medicare covers the Annual Wellness Visit at no cost. It does not cover a traditional annual physical. If your doctor examines or addresses a health problem during the same appointment, that portion is billed as an office visit with your standard 20% cost share. To avoid an unexpected charge, tell your doctor at the start of the visit that you are there for your Annual Wellness Visit only. If you also need to discuss a health issue, ask whether that should be a separate appointment.
Complete Medicare preventive care schedule Coming soon
Full list of covered preventive services with frequency limits, eligibility requirements, and how to request each one correctly.
Topic eight
What to review every year
Medicare is not a set-it-and-forget-it system. Plans change every year. Networks change. Drug formularies change. Premiums change. The people who get blindsided mid-year are the ones who did not review their coverage each fall when the review window is open and the information is available.
By September 30 each year
Annual Notice of Change arrives
Your Medicare Advantage or Part D plan is required to mail you an Annual Notice of Change by September 30. It lists every change to your plan's premiums, coverage, network, and drug formulary for the coming year. Read this before October 15. This document tells you whether your plan is still right for you.
October 15 through December 7
Annual Enrollment Period
The main annual window. Switch between Original Medicare and Medicare Advantage. Change your Medicare Advantage plan. Change your Part D drug plan. All changes take effect January 1. This is your one guaranteed opportunity each year to respond to plan changes.
January 1 through March 31
Medicare Advantage Open Enrollment
If you are in Medicare Advantage and want to switch to a different Advantage plan or return to Original Medicare, this is a second window. It does not allow switching from Original Medicare into Medicare Advantage. Changes take effect the first of the following month.
Year-round
Special Enrollment Periods
Certain life events open a limited enrollment window outside the standard periods. Moving out of your plan's service area, losing other coverage, and several other qualifying events each trigger a Special Enrollment Period. If your situation changes significantly, check whether one applies before the window closes.
Most people never read the Annual Notice of Change. That is why plan changes surprise them mid-year.
When your plan mails the Annual Notice of Change in late September, the instinct is to set it aside. Do not. The document tells you specifically what is changing. If your doctor is leaving the network, if a drug you take is moving to a higher cost tier, or if your premium is increasing, you will see it here. If you do not read it, you will not know until you are at the doctor's office or at the pharmacy counter.
Step 1: Pull together your current medication list - every drug, the dose, and how often you take it. Include occasional medications as well as daily ones.
Step 2: Go to medicare.gov/plan-compare and enter your zip code and full medication list. The tool shows every Part D plan in your area and your estimated total annual cost under each plan based on your specific prescriptions.
Step 3: Sort results by estimated annual drug cost, not monthly premium alone. A plan with a $10 monthly premium and high drug copays often costs more than a plan with a $45 premium and lower copays. The total cost is what matters.
Step 4: If a better-fit plan exists, switching is done directly in the Plan Finder tool or through the plan's website between October 15 and December 7. Coverage starts January 1.
Important 2025 change: The annual out-of-pocket cap for Part D covered drugs is now $2,000. Once you have spent $2,000 on covered Part D drugs in a calendar year, your cost-sharing stops for the rest of the year. If you take expensive specialty medications, this cap significantly reduces your annual exposure.
Switching from Medicare Advantage back to Original Medicare is done during the Annual Enrollment Period or the Medicare Advantage Open Enrollment Period through medicare.gov or by calling 1-800-MEDICARE. The mechanics are straightforward.
The complication is Medigap. When you return to Original Medicare, you are not automatically entitled to a Medigap plan. In most states, insurers can review your health history and decline your application or charge higher premiums. The guaranteed issue right you had at 65 does not automatically return when switching back.
There are exceptions. If your Medicare Advantage plan involuntarily leaves your service area, goes bankrupt, or disenrolls you, you gain a guaranteed issue right to certain Medigap plans. A SHIP counselor can evaluate whether a qualifying event applies to your specific situation.
This is why the Original Medicare vs. Medicare Advantage decision is worth thinking through carefully at the beginning rather than assuming it is easily reversible later.
About the figures on this page.
Dollar amounts and program thresholds reflect published 2025 rates from the Centers for Medicare & Medicaid Services (CMS) and the Social Security Administration (SSA). CMS adjusts most figures annually, typically in the fall before each coverage year. Verify current rates at
medicare.gov
or
ssa.gov
before making enrollment or coverage decisions.
Project Kos is an educational resource. Nothing on this page is legal, financial, or medical advice.
