Medicare Planning 101: Your Guide to Medicare Open Enrollment

With the Medicare open enrollment period coming soon (Oct. 15th to Dec. 7th), you may be actively researching coverage options. Whether you are contemplating changing your current coverage or are approaching 65 and making these decisions for the first time, understanding all the various considerations is essential. This Medicare planning guide will help you navigate the fundamentals of Medicare, enrollment periods, coverage options, and other important details to make informed decisions about your healthcare.

While the One Big Beautiful Bill Act (OBBBA) signed into law on July 4th, 2025 made significant changes to Medicaid, Medicare was left with no major overhaul.

Medicare Planning: Overview of Medicare Parts

Medicare is a federal health insurance program for people age 65 and older. There are 3 main types of Medicare coverage, referred to as “parts.”

Medicare Part A

Includes coverage for in-patient hospital, skilled nursing, hospice, and home health care.

• No premiums, if you paid into the Medicare system for 10 years. The premium is $518 per month for those with less work history, or $285/mo. if you worked between 7.5 and 10 years.
• Deductible is $1,676, resetting each year.
• Coinsurance that you pay varies depending how long you stay / your care is for.

Medicare Part B

Includes coverage for out-patient doctor visits, lab tests, ambulance, outpatient therapy, preventative services. Not covered are dental care, hearing aids, and eye exams.

• Premium is $185/mo. Premiums rise from here for high earners under IRMAA (“Income-Related Monthly Adjustment Amount”). The maximum premium for the highest income level is $628.90.
• Deductible is $257, resetting each year.
• Coinsurance – After deductible is met, you pay 20% of the Medicare-approved amount.

Medicare Part D

Includes coverage for prescription drugs.

• Premiums, deductibles, and co-pays vary by plan.

Medicare Planning: Two Paths

In order to understand how to access these coverage options and their respective Medicare open enrollment periods, it is crucial to understand the two main coverage path options: Original Medicare and Medicare Advantage.

Path One: Original Medicare

The first path is called Original Medicare because it was the only option from when it was first enacted in 1965 until 1999. Parts A and B are obtained through the federal government, and Part D is purchased separately from a private insurance company approved by the federal government. It is also common for folks on Original Medicare to purchase Medicare supplemental coverage, known as “Medigap” or “Med Supp” to fill in any gaps in coverage.

Path Two: Medicare Advantage

Medicare Advantage (also referred to as Part C) began as an option in 1999. Parts A, B, and D coverages can be purchased in a bundle. Most Medicare Advantage plans also cover routine dental, hearing, and vision services. Often, Medicare Advantage will have no premiums and no deductibles, but will have co-pays up until MOOP (maximum out of pocket) has been reached.

Which Path Should You Choose?

In deciding between Original Medicare and Medicare Advantage, the best option depends on your specific situation. Some key considerations include medical history, medical networks, travel tendencies, prescription needs, etc. However, the most important consideration for you to analyze is the total estimated cost (premiums, deductibles, and co-pays) between the two paths. While some providers might promote no premiums, the other two components of the total cost may be substantially higher than alternatives.

Make sure you are making an apples-to-apples comparison. You probably will have more coverage in a Medicare Advantage plan than you would in an Original Medicare plan. Along with hearing, dental, and vision, Medicare Advantage plans can sometimes also include coverage for a gym membership, acupuncture, nutritional programs, and other benefits. However, Medicare Advantage can also have a narrower network of providers and may require more referrals to see specialty providers.

Out-of-pocket maximums are also different between the two paths. Medicare Advantage can have a MOOP of up to $9,350 for in-network services (although many MOOPs are lower). The out-of-pocket max for Original Medicare with Medigap depends on the type of Medigap policy you choose (such as plan F or G, for example). It is helpful to model out what a healthy year, a minor medical needs year, and a major medical needs year might look like under the various paths. Often, it comes down to what level of uncertainty you are okay with. Original Medicare with a Medigap Policy provides more of a known out-of-pocket amount for a given year, sometimes benefiting more in a higher medical needs year, but not in a healthy year. On the other hand, Medicare Advantage often has low upfront premiums but requires that you pay as you go until hitting the MOOP. Ultimately, the decision is highly dependent on your specific medical needs.

Warning

For those working past age 65, it is important to know how Medicare and employer coverage interact. If your employer has fewer than 20 employees and you work past 65, the employer’s plan is secondary coverage. Medicare would be your primary coverage. So, if you did not apply for Medicare in this situation, you would have no primary health insurance.

Medicare Enrollment Periods

As if keeping up with all the different parts and paths of Medicare weren’t enough, there are various enrollment periods when applying for Medicare/changing coverages. Key enrollment periods include:

• Automatically Enrolled: If you are receiving Social Security benefits by age 65, you’ll automatically be enrolled in Part A and Part B.
• Initial Enrollment Period: This window spans seven months—beginning three months before your 65th birthday month, your birthday month, and ending three months after your birthday month. Enrolling during this window helps you avoid late enrollment penalties (up to 20%) and coverage gaps.
  • You can join any plan, but you need both Part A (Hospital Insurance) and Part B (Medical Insurance) to join a Medicare Advantage Plan with or without drug coverage. So, you would first enroll in Original Medicare A and B, and once you have a Medicare number you can then enroll in a Medicare Advantage plan
  • You’ll need either Part A or Part B to join a Part D plan.
• General Enrollment Period: Additionally, you can sign up for Part A and/or Part B coverage during the General Enrollment Period, which runs from January 1 to March 31 each year.
  • You don’t want to have to rely on this enrollment period, as it is for those that didn’t sign up when they were initially eligible and don’t qualify for a Special Enrollment Period. As a result, you may be subject to a late enrollment penalty, with coverage starting July 1.
• Medicare Open Enrollment Period: Also known as the Annual Enrollment Period, from Oct 15-Dec 7, you can make a wide range of changes to your coverage. This is for those who have Original Medicare or a Medicare Advantage plan. You can switch to/from Original Medicare and Medicare Advantage, switch coverage providers, and add/drop Part D. New coverage starts Jan 1 of the following year. Remember to review your coverage annually to see if there are any changes that need to be made
  • Warning: if changing from Medicare Advantage to Original Medicare and you consequently want a Medigap Plan, medical underwriting may be required.
• Medicare Advantage Open Enrollment Period: From Jan 1-March 31, this period gives one additional chance for those with Medicare Advantage to make changes to another Medicare Advantage plan with or without drug coverage or move to Original Medicare. You cannot make changes under this enrollment period if you have Original Medicare coverage.
  • Warning: if changing from Medicare Advantage to Original Medicare and you consequently want a Medigap Plan, medical underwriting may be required.
• Medigap Open Enrollment Period: This is a six-month period that begins the month you turn 65 or older and are enrolled in Medicare Part B.
  • During this window, you can enroll in any Medigap policy sold in your state penalty-free. In order to avoid medical underwriting, enroll during this period.
• Special Enrollment Period: There are special enrollment periods for life events such as moving address, being covered by an employer plan past age 65, losing coverage when leaving your job, and getting Medicaid.

You may be able to join an Original Medicare or Medicare Advantage Plan with coverage starting the first day of the month after your request.

How to Enroll in Medicare?

You can enroll in Medicare through several methods:

• Online at Social Security’s website – Medicare
• By phone at 1-800-772-1213
• In person at your local Social Security office

Extra Help Needed? 

Work with a professional (licensed agent or volunteer counselor – NC SHIIP volunteer). These volunteers are strictly there to help and are not affiliated with any insurance company. You can also call 1-800-MEDICARE (1-800-633-4227) for the Official Medicare helpline. For those wanting to dig more into all the details, refer to the Official Medicare Handbook.

As always, Verum Advisers are here to answer questions and provide clarity as you navigate your options.

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