The Annual Notice of Change arrives by September 30. The Summary of Changes in the first 4–6 pages is everything you need. Premium, deductible, OOP maximum, formulary tier changes, network changes, supplemental benefit changes. If you read nothing else, read those pages before October 15.

• Premium change — your new monthly cost starting January 1
• Deductible change — what you pay before coverage begins
• OOP maximum (MA plans) — worst-case annual exposure
• Formulary changes — search for your drug categories specifically
• Network changes — has your physician, specialist, or hospital been removed?
• Supplemental benefits (MA) — dental, vision, hearing, fitness changes

Part D formularies reset every January 1. Your drug's tier can move — from $30 to $150 per month — without the drug changing at all. The only way to know what your drugs cost next year is to run the comparison through Medicare's Plan Finder. Most people never do this. Those who do it every year save an average of $300–700 annually by switching to a plan that covers their specific drugs better.

• Go to medicare.gov/plan-compare and click "Drug Plan (Part D)"
• Enter your zip code, then your current drug list — every drug, dose, and quantity per fill
• View estimated total annual cost sorted cheapest first
• Compare your current plan vs. the 2–3 least expensive alternatives
• Confirm your preferred pharmacy is in-network for any plan you consider
• Contact a SHIP counselor for free assistance — shiphelp.org

MA plans can change substantially year to year. CMS releases updated star ratings in October — a plan's rating affects quality and predicts future stability. A plan right for you in 2023 may have contracted its network, increased its OOP max, or dropped in star rating by 2026.

• Network: are your PCP, specialists, and preferred hospital still in-network?
• OOP maximum: what is the worst-case annual out-of-pocket?
• Drug formulary: run your drugs through Plan Finder for the MA-PD version of your plan
• Star rating: check the updated rating at medicare.gov/plan-compare — look for drops from prior year
• Supplemental benefits: dental, vision, hearing, fitness — what changes for the new year?

• Plan dropped 1+ star rating
• A key provider or hospital left the network
• OOP maximum increased significantly
• Most costly drugs moved to higher tier vs. available alternatives

If you did not act during Annual Enrollment — or enrolled in an MA plan that is not working — the MA Open Enrollment Period (Jan 1–Mar 31) gives you one additional chance. You can switch from one MA plan to another, or switch from MA back to Original Medicare with a Part D plan. The OEP is not available to switch from Original Medicare into MA.

• Switch from your current MA plan to a different MA plan
• Switch from MA back to Original Medicare and enroll in a Part D plan
• You cannot switch from Original Medicare to MA during OEP

• Enroll in a Part D plan at the same time — do not leave a coverage gap
• If you want Medigap, your guaranteed-issue window has typically passed — medical underwriting may apply in most states (exceptions: plan terminated, you moved out of service area)

IRMAA is a surcharge added to Part B and Part D premiums for beneficiaries whose modified adjusted gross income exceeded the threshold two years prior. For 2026, the threshold is $109,000 for individuals ($218,000 joint) — based on 2024 tax returns. Applied automatically by Social Security. A large one-time income event — property sale, Roth conversion, large RMD — can trigger it unexpectedly.

• $109,001–$137,000: total Part B premium $284.10/mo (+$81.20 over base)
• $137,001–$171,000: $405.80/mo (+$202.90)
• $171,001–$205,000: $527.50/mo (+$324.60)
• $205,001–$500,000: $649.20/mo (+$446.30)
• Over $500,000: $689.90/mo (+$487.00)
• Part D surcharge also applies: +$14.50 to +$91.00/mo depending on tier

• If your income dropped significantly since the base year, file Form SSA-44 with Social Security
• Qualifying life events: marriage, divorce, death of spouse, work reduction, work stoppage, employer pension loss
• A one-time income event (property sale) does not automatically qualify — explain the circumstances; Medicare has discretion for non-recurring events

Extra Help (also called the Low-Income Subsidy, or LIS) pays most or all of a beneficiary's Part D costs — premiums, deductibles, and copays. In 2026, the full LIS caps drug copays at $5.10 for generics and $12.65 for brand drugs (2026). QMB-enrolled patients with income below the federal poverty level pay even less — $1.60 generics / $4.90 brand. For individuals with income under 150% of FPL (~$21,780 for a single person in 2026), the subsidy is automatic with Medicaid enrollment. Others must apply. About 2.5 million people who qualify have not enrolled.

• Apply online at ssa.gov/extrahelp
• Call Social Security at 1-800-772-1213
• Contact your State Medicaid office — Medicaid enrollment typically confers automatic LIS
• SHIP counselors can help with the application at shiphelp.org

The AWV is a $0 benefit that does more than most people expect. It includes a cognitive assessment, depression screening (PHQ-9), fall risk assessment, functional ability review, and a personalized prevention plan listing all screenings you are eligible for. It also provides structured time to review your full medication list. Most patients never request it because they do not know it exists separately from a standard office visit.

• Schedule specifically as the Annual Wellness Visit — not a "checkup" or "annual physical"
• Bring a complete, current medication list — every drug, supplement, and OTC product
• Ask the physician to print your personalized prevention plan
• Ask whether you qualify for Chronic Care Management billing
• Ask about cognitive health — request a formal MMSE or MoCA screen if you have any concerns

• Colorectal cancer screening — colonoscopy every 10 years (every 2 for high-risk)
• Mammogram — annually for women 40+
• Lung cancer CT scan — annually for current/former heavy smokers ages 50–77
• Bone density — every 2 years for women 65+ or at-risk
• Depression screening — annually for all beneficiaries
• Diabetes screening — every 3 years if at-risk, annually if pre-diabetic
• Alcohol misuse screening — annually

If you have two or more chronic conditions expected to last at least 12 months, your physician can bill Medicare monthly for structured care coordination — phone check-ins, medication management, care plan maintenance, specialist communication, and patient education. Physician bills at least 20 minutes per month. You pay the 20% Part B coinsurance (waived with Plan G or N, roughly $10–15 without supplement). Studies show CCM enrollment reduces hospitalizations by 15–20%.

• Ask your PCP: "Do you offer Chronic Care Management?" Some practices call it care coordination or population health management
• You must give written consent to enroll
• Only one provider can bill CCM for you per month — it should be your primary care provider
• Delivery is typically by a care coordinator under physician supervision, not the physician directly

The average Medicare patient with multiple chronic conditions sees 5–7 different providers per year. Each has access to their own notes but may not see the full picture. Medication conflicts, duplicate testing, contradictory advice, and care gaps all emerge from fragmented care. The PCP is the intended coordinator — but only if they receive information from the specialists. In the current system, they often do not.

• Get a visit summary or after-visit notes from the specialist
• Send those notes to your PCP's office via patient portal or fax
• Ask the specialist: "Will you send a note to my primary care physician?"
• Maintain your own master medication list — updated after every prescription change from any provider
• At each PCP visit: bring the complete medication list and ask for a review of everything

Part D plans must identify high-risk members for MTM — typically those with 3+ chronic conditions, 8+ Part D drugs, and drug costs above a threshold. These members receive a free Comprehensive Medication Review by phone with a pharmacist. The review covers every drug you take, potential interactions, duplications, adherence barriers, and whether each drug is still indicated. The CMR typically takes 45–60 minutes and produces a written action plan.

• If you qualify, your Part D plan must contact you — but the contact is often a letter that looks like junk mail
• Call your Part D plan and ask: "Am I enrolled in the Medication Therapy Management program?"
• If you do not qualify for MTM, ask your PCP for a medication review at your AWV

Vaccine coverage under Medicare splits between Part B and Part D in ways that confuse patients — the wrong setting can result in unexpected costs. Starting in 2023, all ACIP-recommended vaccines are covered at $0 under Part D when obtained at a pharmacy, including Shingrix, RSV vaccines, and pneumococcal vaccines. Part B covers flu, COVID, and pneumococcal at a physician's office at $0.

• Flu: annually every fall — Part B at $0 at physician or pharmacy
• COVID-19: updated annual shot — Part B at $0
• Shingrix (shingles): 2-dose series — Part D at $0 at pharmacy
• Pneumococcal (PCV15/PCV20 + PPSV23): series for adults 65+ — Part B or Part D at $0
• RSV: single dose for adults 60+ — Part D at $0 at pharmacy
• Tdap: one dose if never received as adult — Part D at $0 at pharmacy

Medicare covers several condition-specific programs that go unused because physicians do not always refer and patients do not know to ask. Each has strong evidence for improving outcomes and reducing hospitalizations — and each is covered at $0 or standard Part B coinsurance rates.

• Diabetes Self-Management Training (DSMT): 10 hours initial + 2 hours/year follow-up. Physician referral required. Part B — 20% coinsurance.
• Cardiac rehabilitation: 36 sessions for qualifying cardiac events (MI, CABG, valve surgery, stable angina, heart failure). Part B — 20% coinsurance.
• Pulmonary rehabilitation: 36 sessions for moderate-severe COPD. Part B — 20% coinsurance.
• Intensive Behavioral Therapy for obesity: 22 visits in year one for BMI 30+. $0 preventive benefit.
• Opioid treatment program: bundled OTP coverage for opioid use disorder. Part B.

Ask your physician at your next visit: "Am I eligible for any Medicare rehabilitation or disease management programs given my conditions?" Bring a list of your diagnoses to your AWV and ask specifically about each program above.

Medicare permanently expanded telehealth coverage after the pandemic. Established patients can use video and audio-only telehealth for most primary care and mental health services — significant for patients with difficulty traveling. However, certain services still require in-person visits, and audio-only visits have more limitations than video. Understanding the distinction prevents delayed care from assuming telehealth covers something it does not.

• Established patient primary care visits — video and audio-only
• Mental health visits — psychotherapy, psychiatry, counseling
• Chronic disease management check-ins
• Annual Wellness Visit — via video (not audio-only alone)
• Behavioral health integration services

• New patient initial visits in most cases
• Physical examination findings that affect diagnosis
• Lab work, imaging, procedures
• Controlled substance prescribing (with narrow exceptions)

A serious new diagnosis — cancer, heart failure, Parkinson's, COPD, kidney disease — changes the entire care landscape. The patient suddenly has new specialists, new medications, new decisions, and a new relationship with the system. Most patients arrive at the first specialty appointment without a plan for how to integrate this new care with existing care. The decisions made in the first 30 days shape what follows.

• Identify which physician is the coordinator — who sees the whole picture across all treating providers
• Get a complete written treatment plan — diagnosis, proposed treatment, alternatives, timeline
• Map how the new treatment affects your current medications and coverage
• Ask specifically: does this diagnosis change my Medicare coverage, plan, or eligibility?
• If the diagnosis is serious: review or create advance directives now — do not wait
• Ask about clinical trials if the diagnosis is cancer — Medicare covers routine costs of trial participation

• Some MA plans have Special Enrollment Periods triggered by specific diagnoses — contact your plan
• A diagnosis that creates nursing-home-level care need may open PACE eligibility
• A VA service-connected condition may change VA priority group and coverage scope
• ALS and ESRD diagnoses accelerate Medicare eligibility regardless of age

Mild cognitive impairment (MCI) and early dementia affect 15–20% of people over 65. Most families recognize the signs but wait years before seeking formal evaluation — often until a crisis makes it unavoidable. Early diagnosis enables planning, access to emerging treatments, legal document preparation while the patient can participate, and potentially enrollment in clinical trials. The cognitive screen at the AWV is designed to catch this early — but only if the AWV happens.

• Repeating the same questions or stories in a single conversation
• Getting lost on familiar routes or difficulty with familiar tasks
• Difficulty managing finances, bills, or medications that were previously handled well
• Personality or mood changes that are new — increased suspicion, anxiety, social withdrawal
• Word-finding difficulties increasing over months
• Missing appointments or events that were previously tracked reliably

• Cognitive testing — MMSE, MoCA, or full neuropsychological battery
• Lab work — thyroid, B12, metabolic panel to rule out reversible causes
• Brain imaging (MRI or CT) to assess structural changes
• Possibly: neurology referral, neuropsychology evaluation, or geriatric assessment

Functional decline is often gradual enough that families accommodate it imperceptibly — driving shifts to the caregiver, meals get simpler, one family member quietly takes over bill paying. Then something happens — a fall, a hospitalization, a caregiver health crisis — and the accommodated decline becomes visible all at once. Catching the decline trajectory before the crisis gives options; after it, options narrow fast.

• Basic ADLs: bathing, dressing, toileting, transferring, continence, eating
• Instrumental ADLs (IADLs): managing medications, managing finances, shopping, cooking, driving, using telephone/technology, housework

Decline in IADLs typically precedes decline in basic ADLs by months to years. The patient who can no longer manage medications reliably is on a trajectory — the question is what comes next and whether you have time to plan it.

• Request a geriatric assessment — comprehensive evaluation of medical, functional, cognitive, and social factors by a geriatric team
• Involve a geriatric care manager (private, fee-for-service) if coordination support is needed
• Contact the Area Agency on Aging (1-800-677-1116) for in-home support programs
• Begin the Stage 6 conversation — while there are still options to choose between

Falls are the leading cause of injury-related death in adults over 65 and the most common trigger for the kind of rapid functional decline that ends Stage 5. One fall with a hip fracture can change everything. But falls are also predictable and preventable — structured fall risk assessment and intervention reduces fall rates by 30–40%. The problem is that the assessment tends to happen after the fall, not before.

• Medications: sedating drugs (benzodiazepines, sleep aids, some antihistamines), blood pressure medications, diuretics at night
• Vision: uncorrected vision loss doubles fall risk — annual eye exams matter
• Footwear: non-slip soles, properly fitting shoes, no loose slippers
• Home hazards: throw rugs, poor lighting, no grab bars, cluttered paths
• Strength and balance: sarcopenia increases fall risk — strength training and balance exercises are evidence-based interventions, covered through Medicare fitness benefits on some MA plans

• Report it to the physician — even if no injury occurred. Document it in the medical record.
• Request a fall risk assessment — most primary care practices have a structured protocol
• Ask for a physical therapy referral for balance training
• Review medications with the physician for fall-risk contributors

Stage 6 is not a failure — it is a transition. The families who navigate it best are the ones who begin the conversation and the planning before the situation is critical. Stage 6 covers assisted living, memory care, Medicaid planning, and the family conversations that make those decisions possible. The worst version of this transition is the one that happens in the emergency room or the hospital discharge planner's office with 48 hours to decide.

• More than two falls in 30 days
• Inability to safely manage medications without direct supervision
• Driving cessation — practical access to activities is now fully dependent on others
• Family caregivers showing signs of burnout — sleep disruption, health decline, social isolation
• Private-pay home care exceeding $6,000/month with no defined asset plan
• Cognitive diagnosis of moderate-stage dementia — safety at home becomes the primary question
• Patient expresses wish to be around others, or family no longer believes home is safe