This article is for informational purposes only and does not constitute medical, legal, or financial advice. Always consult with qualified professionals regarding your specific situation.

Medicare Plan Comparison Guide — Making the Annual Enrollment Decision

Every fall, Medicare sends notices about plan options and changes. Premium prices shift. Formularies change—meaning which drugs are covered and how much they cost. Doctor networks expand or contract. It's easy to ignore all of it, keep your same plan, and hope for the best. It's also easy to miss savings or end up with worse coverage than you could have had. The decision matters enough to spend an hour comparing your options.

The process feels overwhelming because Medicare is genuinely complex. There are different plan types, different coverage rules, different costs depending on where you live. But the actual decision-making process is manageable if you focus on the right questions. You're comparing plans based on how much you'll pay in total—premiums, deductibles, copays, and coinsurance,and whether the doctors and drugs you use are covered.

Let's break down the main plan types first, then work through how to compare them.

Original Medicare Versus Medicare Advantage

Original Medicare is traditional Medicare. You have Part A (hospital coverage) and Part B (doctor and outpatient care). You can see any doctor who accepts Medicare. You pay the costs that Medicare doesn't cover,deductibles, copays, and coinsurance,unless you have additional coverage.

Medicare Advantage is an alternative. It's a managed care plan run by a private insurance company. These plans must cover everything Original Medicare covers, but they do it through networks. You have a primary care doctor you go to first (usually). You need referrals to see specialists. You typically pay lower premiums and out-of-pocket costs than Original Medicare with a supplement. But you're restricted to a network.

Which is better? It depends on your situation. If you travel a lot or like the freedom to see any doctor, Original Medicare is usually better. If you have a primary doctor you like and don't mind a network structure, Medicare Advantage might save you money. The decision isn't forever,you can switch during annual enrollment periods.

Some Medicare Advantage plans include dental, vision, and hearing. Original Medicare doesn't cover those, so if you need those services, that affects your total cost comparison.

Prescription drug coverage is included in most Medicare Advantage plans. With Original Medicare, you need a separate Part D plan for drug coverage.

Understanding Prescription Drug Coverage

This is where careful comparison really matters. Two similar-looking plans can have very different out-of-pocket costs for the medications you actually take.

Start by listing the medications your parent takes. Get the exact names, doses, and frequencies. Then look up those specific drugs in each plan's formulary,that's the list of covered medications. Is each drug on the formulary? If a drug isn't covered, it's not covered. That's a dealbreaker if it's a medication they need.

Some drugs have restrictions. Preferred drugs have lower copays. Non-preferred drugs have higher copays. Some drugs require "prior authorization",meaning the doctor has to get approval from the insurance company before filling it. Some drugs have quantity limits,like "we'll pay for 30 pills per month but not more." These restrictions affect how much it costs.

The deductible is what you pay before the plan starts paying. If the deductible is 500 dollars and your medications cost 40 dollars a month, you'll pay out of pocket until you've spent 500 dollars total. After that, the plan kicks in and you pay copays.

Cost-sharing varies. One plan might charge a 10-dollar copay for generics and 50 dollars for brand names. Another might charge 15 dollars and 75 dollars. That difference matters when you're filling prescriptions monthly.

Watch for the donut hole if the person has high drug costs. The donut hole is coverage gap that exists in some Part D plans. You pay some amount, then you hit a gap where you pay more, then catastrophic coverage kicks in. The specifics of gaps vary by plan and year. If someone has expensive medications, donut hole rules affect their total cost significantly.

Run your parent's actual medications through the plan comparison tools on Medicare.gov. The tools show you exactly what the out-of-pocket cost will be for each plan based on the drugs they take. This real-number comparison beats any general principle.

Supplemental Coverage,Medigap

If your parent has Original Medicare, they likely also have a Medigap plan (supplemental insurance). Medigap covers costs that Original Medicare doesn't,deductibles, copays, and coinsurance. There are ten standardized Medigap plans, labeled A through N. Plan G is popular. Plan N is popular because it's cheaper. Different plans cover different amounts.

When comparing Original Medicare options, look at the total cost including the Medicare premium, the Medigap premium, and the Part D drug plan premium, plus the deductibles and copays you'll actually pay. It's not just the base Medicare premium.

If someone is switching from Medicare Advantage to Original Medicare plus Medigap, they need to understand the cost change. Medicare Advantage has lower premiums usually but can have higher out-of-pocket costs. Medigap has higher premiums but covers most out-of-pocket costs. The total cost might be similar, but the structure is different.

Evaluating Networks and Providers

If looking at Medicare Advantage, check whether the doctors your parent sees are in-network. A plan that seems affordable is worthless if your parent's longtime cardiologist isn't in the network. Look up each doctor. Some are listed as in-network, some as out-of-network (costs more), and some as not contracting.

Check hospitals too. If your parent goes to a specific hospital, make sure it's in-network.

Ask about specialist referrals. Do they need them? How easy is it to get one? How quickly can they see the specialist?

When Costs Change

Premiums change every year. The Part B premium might go up. Medigap premiums go up. Plan costs shift. Something that's cheapest this year might be expensive next year. This is why annual review matters.

Formularies change. A drug covered this year might not be covered next year, or its copay might change. If someone takes medications that are at risk of being dropped from formularies, or if they take newly approved expensive drugs, those changes matter.

Deductibles reset January 1st every year. Out-of-pocket maximums reset. Someone who's already met their deductible in December starts over in January. Timing of high-cost procedures can matter if someone's close to an out-of-pocket maximum.

Special Situations

Life changes can trigger special enrollment periods. If someone loses coverage, gets married, moves to a different state, or has a major change in income, they might be able to change plans outside of the annual enrollment period. If these situations apply, ask about it.

If someone's income is low, they might qualify for Extra Help (subsidies for prescription drugs) or for Medicaid to wrap around Medicare. These can significantly lower costs. It's worth checking, even if you think income is too high.

The Actual Comparison Process

Create a simple spreadsheet. List each plan option your parent qualifies for. Write down the premium, the deductible, the copays for regular doctor visits and specialists, and the out-of-pocket maximum. Then write down the real costs they'll face based on how much they go to doctors and what medications they take.

The out-of-pocket maximum is what they'll pay in total before insurance covers everything at 100%. If someone's healthy with low medical costs, the out-of-pocket maximum barely matters. If someone's chronic and goes to lots of appointments or takes expensive drugs, knowing the maximum is important.

Then run their medications through the drug coverage calculator. Add that cost to everything else. That gives you the real total cost for each plan.

Plans that look expensive at first glance sometimes end up cheaper once you factor in real usage. Plans that look cheap sometimes become expensive when you add in medications and out-of-pocket costs. Real numbers beat general impressions.

Annual review takes time, but for someone on Medicare, the money matters. Small premiums or copay differences multiply over twelve months. If this is someone you're responsible for helping, helping with plan review is time well spent.

How To Help Your Elders is an informational resource for families working through aging and elder care. We are not medical professionals, attorneys, or financial advisors. The information provided here is for educational purposes and should not replace professional consultation. Every family's situation is unique, and rules, costs, and availability vary by location and circumstance.