It’s a thought that likely crosses the mind of anyone who has Medicare when thinking about their coverage: Should I switch my Medicare plan?
If you’re happy with it, clearly, you probably should stick with what you have, but even if you’re pleased with it, some experts suggest at least comparison shopping during the open or annual enrollment period, just in case you find something better.
“I tell clients to treat a Medicare plan like a one-year contract, because that is exactly what it is,” says Stefanie L. DeMario-Germershausen, an attorney and partner at Angiuli & Gentile LLP. She leads the firm’s Estates, Trusts, Real Estate and Medicaid Departments. DeMario-Germershausen is based out of New York City.
“The plan renews automatically if you do nothing, but it doesn’t renew on the same terms. Premiums, formularies and networks reset every January. Waiting until you find yourself grumbling means you have likely already absorbed a year of avoidable costs,” DeMario-Germershausen says.
So when should you switch Medicare plans? Here are what experts say are generally very good reasons to make a change to your Medicare coverage.
[READ: Does Medicare Require Prior Authorization?]
1. Your Doctor or Pharmacy Is No Longer In-Network
This is a common reason people switch Medicare plans, according to Dr. Lakshmi Halasyamani, chief clinical officer at Endeavor Health, a healthcare system throughout the Chicago area. She says it’s one of the three main red flags that should cause somebody to make a switch.
Networks change every year, so the odds are decent that a physician, specialist, hospital or your pharmacy could leave your plan.
DeMario-Germershausen agrees. “Loyalty to a plan should never outrank access to your own doctors,” she says.
[Read: What to Do if Your Doctor Stops Accepting Medicare]
2. You Want to Save Money on Medicare Premiums and Out-of-Pocket Costs
Switching Medicare plans because you want to spend less is often a trigger for people to decide to look and see if there’s something better out there.
“Increases in premiums, copays, deductibles or out-of-pocket maximums are all good reasons to review your options during the appropriate enrollment window,” says Danielle Roberts, a co-founding partner at Boomer Benefits, an agency based out of Fort Worth, Texas, specializing in Medicare-related insurance products.
In fact, Roberts encourages Medicare members to not wait to be blindsided by a price change.
“Medicare enrollees should be reviewing their coverage every year during the annual enrollment period, even if they decide to keep their plan. That doesn’t mean switching, but simply confirming that your doctors, prescriptions and costs haven’t changed in ways that affect your budget can save you from staying on top of it,” Roberts says.
How much could you save by switching Medicare plans?
Tthere isn’t much recent research on what the average savings is. But Roberts says that for those with a Medicare supplement, or Medigap, plan who are healthy enough to qualify for underwriting, “my team typically sees clients, on average, saving $500 to $1,000 per year by moving to a lower-priced plan with the same standardized benefits.”
She adds: “In some cases, people who have been on the same Medigap plan for many years may see savings of $2,000 to $3,000 annually.
Roberts says that if you move from Medigap to Medicare Advantage, you may do even better.
“Someone paying $140 to $180 per month for a Plan G could be spending roughly $1,700 to $2,200 per year in Medigap premiums alone. Moving to a $0 premium Medicare Advantage plan could eliminate that monthly premium cost,” she says. “However, it’s important to weigh the savings against the plan’s cost-sharing structure and potential for higher out-of-pocket costs.”
In any case, old-fashioned comparison shopping, which you can do on your own or by working with a Medicare broker, is imperative.
“The biggest savings for those enrolled in Medicare Advantage plans often come from finding a plan that better fits their healthcare needs,” Robert says. “Smaller copays, lower maximum out-of-pocket limits and better prescription drug coverage can reduce healthcare costs by hundreds or even thousands of dollars depending on the services and medications they use.”
The wrong plan can really send pharmaceutical prices soaring, according to DeMario-Germershausen, adding that that can help especially if a medication is dropped from the plan’s formulary or moved to a higher tier.
“Even one drug being re-tiered can swing a senior’s annual costs by thousands of dollars,” she says.
[READ: 7 Reasons to Switch Medicare Part D Plans in 2026]
3. You Experience a Major Life Change (Medicare Special Enrollment Period)
Changes in health status or financial situation are two other major reasons for switching Medicare plans, says Halasyamani.
The good news is that you don’t have to wait until the annual open enrollment period in the fall. You can do it during what’s known as the special enrollment period, or SEP, for major changes in your life.
These qualifying events trigger a Medicare special enrollment period, allowing consumers to change their plans outside of standard enrollment windows:
— A Permanent Move: Relocating to a new address outside of your current plan’s service area, moving back to the U.S. after living abroad or moving into, out of or residing in a qualified institutional facility (such as a nursing home).
— Loss of Existing Coverage: Involuntarily losing health or prescription drug coverage from an employer, union, COBRA or losing eligibility for Medicaid.
— Gaining New Coverage Opportunities: Becoming newly eligible for alternative health coverage through a current employer, union or a spouse’s plan.
— Changes in Financial Assistance: Gaining, losing or experiencing a change in eligibility for government financial aid programs like Medicaid or a Medicare Savings Program.
— A New Chronic Health Diagnosis: Developing a severe, disabling or chronic medical condition (such as cardiovascular disease, diabetes or chronic lung disorders) that makes you newly eligible to switch into a specialized Chronic Special Needs Plan.
— Plan Contract Terminations or Violations: If your current insurance carrier leaves the Medicare program, changes its service area, drops its contract with Medicare or fails to meet federal performance guidelines.
— Exceptional Circumstances and Natural Disasters: Being unable to make a plan change during the standard fall or winter enrollment windows due to a government-declared state of emergency or a natural disaster.
“The SEP can be used for a variety of circumstances — (being in) disaster areas, a move from one county or state to another, return to living in the U.S., etc. — any major life change approved by the Center for Medicare and Medicaid Services,” says Elisa Karen Ball, a Boca Raton, Florida-based Medicare insurance advisor at Advocate Health Advisors.
“For example, if a major storm affects an area and the beneficiary cannot participate in the AEP or OEP, this will qualify for a special enrollment period and allow them to change their Medicare coverage,” Ball says.
(OEP stands for open enrollment period, which lasts from January 1st to March 31st. AEP is the annual enrollment period that lasts from October 15th to December 7th.)
If your health takes a turn for the worse, that, too, can mean you are eligible to change your Medicare plan during the SEP, Ball says. She offers up the example of a Medicare beneficiary developing cardiovascular, diabetes, lung or neurological disorders.
“Many insurance companies offer C-SNP (chronic special needs) plans,” Ball says. These chronic special needs plans “can be enrolled in at any time during the year, with a doctor’s diagnosis verification, and are effective on the first day of the month following enrollment.”
Medicare enrollment periods
| Enrollment Period | Dates | Who It Is For | What You Can Do |
| Annual Enrollment Period | Oct 15 — Dec 7 | All Medicare beneficiaries | Switch from original Medicare to Medicare Advantage or change Part D prescription plans |
| Open Enrollment Period | Jan 1 — Mar 31 | Current Medicare Advantage holders | Switch to a different Medicare Advantage plan or return to original Medicare |
| Special Enrollment Period | Varied (For most qualifying life events, beneficiaries have a two-month window from the date of the event to execute their plan switch.) | Qualifying individuals | Change plans due to moving, losing job coverage, natural disasters or severe diagnoses |
[READ: Does Medicare Cover Chronic Pain Management?]
4. You Want Better Coverage for Dental, Vision or Hearing
There’s nothing wrong with wanting a different Medicare plan because you want something better. Medicare Advantage plans, for instance, often have extra benefits that original Medicare plans don’t, such as coverage for routine dental care, vision and hearing. Some offer free access to gyms or free transportation to doctors.
Just don’t get starry-eyed over benefits like a free gym membership. The bottom-line should be the cost of the health plan and the important stuff, like whether you can use the plan with your doctor.
Making the leap from one Medicare plan to another, however, is often pretty easy, according to Halasyamani.
“During the open enrollment period, it is pretty straightforward to switch plans or go from traditional Medicare to a Medicare Advantage plan,” Halasyamani says.
However, she warns that switching back to traditional Medicare from a Medicare Advantage plan is more complex. In many states, you lose the guaranteed right to buy a supplemental Medigap policy later on and may be required to pass a medical assessment.
[SEE: Preventing Costly Medicare Mistakes: Tips and Strategies]
5. Your Current Plan Frequently Denies Prior-Authorization or Claims
This is also a very valid reason to make the switch from the Medicare plan you have. DeMario-Germershausen says that it’s time to say good-bye, if “you are fighting the plan more than the plan is working for you.”
She says the signs include repeated prior-authorization denials, delayed approvals and claim disputes. In those cases, she says, they aren’t just annoyances: “They are a pattern, and patterns rarely improve.”
[READ: How SHIPs Can Help With Your Medicare Questions and Problems.]
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Switching Medicare Plans: 5 Good Reasons to Change Coverage originally appeared on usnews.com
