By asking the right questions about Medicare, you can avoid unexpected costs and penalties. These considerations will also guide you as you choose the Medicare plan that best suits your health needs and lifestyle.
Common Medicare Annual Enrollment Period Questions
This list of frequently asked questions covers a range of Medicare topics. To get started, here are six questions that address what you need to know about Medicare to make sure you can find the best health insurance plan for your needs and budget.
[READ: Medicare Mistakes to Avoid.]
1. When Is Medicare Open Enrollment?
While the annual fall open enrollment is typically what people think of when talking about Medicare enrollment periods, there are actually several times when you can sign up for or make changes to Medicare coverage:
— Initial Enrollment Period. When you approach your 65th birthday, you become eligible for Medicare. You can sign up for Medicare during a seven-month time period, known as “initial enrollment,” that starts three months before you turn 65 and continues through three months after your birthday month.
— Medigap Open Enrollment Period. Also known as the guaranteed issue period, this usually coincides with your initial enrollment period. Some states have additional periods where people can get any Medigap plan they want or switch Medigap plans without being charged more if they have health problems — but in most states, there is a limited period to enroll in a Medigap plan.
— Annual Enrollment Period. Between October 15 and December 7 every year, Medicare beneficiaries can change plans, switch from original Medicare to a Medicare Advantage plan, or join, change or discontinue a Medicare Part D drug coverage plan.
— Medicare Advantage Open Enrollment Period. From January 1 through March 31 each year, Medicare Advantage members can switch to a different Medicare Advantage plan or change to original Medicare. Also, it’s important to note that in most states, you may not be guaranteed eligibility for a Medigap plan if you initially sign up for a Medicare Advantage plan and then decide to switch back to original Medicare later.
— Special Enrollment Period. Experienced a life-changing event, such as getting married, losing other health coverage or moving out of your plan’s service area, triggers an SEP. During these limited periods — typically about 60 days — you can enroll in a new plan.
[Read: When Can You Sign Up for Medicare?]
2. Do You Have Any Expensive Procedures or Tests Coming Up?
If you have health issues or you know that you’ll need expensive tests and procedures in the next year, you should think about deductibles when choosing your Medicare plan for the year. The more health risks and conditions you have, and the older you get, the more likely it is that unexpected and potentially costly health problems will arise over the next year. Choosing a plan with higher premiums but lower deductibles and out-of-pocket costs for hospitalization may be the most sensible choice.
On the other hand, if you’re not anticipating any changes in your health needs, sticking with a lower-premium plan — such as a Medicare Advantage plan with a $0 premium — may be a better bet.
“A good candidate (for Medicare Advantage) is someone who can understand the rules and embrace them,” notes Barbara Hopkins, a Portland, Maine-based, self-employed Medicare educator with nearly 30 years of experience in health payer operations.
“Second of all, if they have not had huge health problems up until the point of being 65, they’re going to be a pretty good candidate because it costs less to join a Medicare Advantage plan, and chances are they are going to be using less expensive services.”
[READ: Medicare vs. Medicare Advantage: How to Choose.]
3. Do All of My Doctors Accept Medicare?
When you’re choosing a plan, look closely at the plan’s network restriction. Seeing an out-of-network doctor versus one available within your plan’s network can affect any out-of-pocket costs you may have to pay.
Medicare
With original Medicare (Part A and Part B), there are basically three types of providers, says Joel Mekler, a health benefits professional, Medicare expert and writer of the “Medicare Moments” weekly column in the New Castle (Pennsylvania) News. These providers are:
— Participating. These providers “accept assignment,” meaning they agree to charge only the amount that Medicare allows for services.
— Nonparticipating. In-network providers who do not accept assignment can charge the patient the difference between what they charged and what the insurance company paid. This charge can be “up to 15% above the amount that Medicare will pay,” Mekler says.
— Opt-out. These providers will not accept Medicare at all. If you want to see a physician who has opted out of Medicare, you will need to pay out of pocket for all of your medical care.
Medicare Advantage
With most Medicare Advantage plans, you’ll be limited to only seeing doctors in the plan’s network, whereas with original Medicare, you can see any doctor, though you may have to pay a higher price to see out-of-network providers.
If you’re considering a Medicare Advantage plan, it’s essential to consider the rules of the Medicare Advantage plan that you’re choosing, Hopkins says. You’ll need to ensure your provider and hospital is in the network. “If they are not, you need to know if it’s possible to see doctors beyond the specific network or not.”
However, there is some flexibility with Medicare Advantage plans. All Medicare Advantage plans are either preferred provider organizations or health maintenance organizations. In general, Medicare Advantage PPO plans will allow you to see a wider network of providers than HMO plans.
“Although a Medicare PPO is a little more expensive, it allows for a larger network,” Mekler says. “In other words, with a PPO, somebody could go in or out of the plan’s network. Unlike with an HMO, you won’t need a referral from your primary care doctor to see a specialist if you have a PPO.”
| Types of Providers | Original Medicare | Medicare Advantage |
| Participating | Covered | “In-network” providers are covered. Those outside are not. HMO plans usually have more restrictive networks while PPO plans are usually wider. |
| Nonparticipating | Partially covered | |
| Opt-out | Not covered |
[Read: What to Do When Your Doctor Leaves Your Health Plan.]
4. Are Telehealth Services Covered?
On September 30, 2025, telehealth flexibilities — which had been expanded during the COVID-19 pandemic — expired and starting on October 1, most telehealth rules reverted to their pre-pandemic state. This means that many Medicare beneficiaries — specifically those who don’t reside in a designated rural area — no longer have the option to see a provider via a remote telehealth visit.
For example, some mental health services can still be delivered via telehealth, but patients must have visited with the provider in person within six months of the telehealth session and an in-person visit must occur at least once every 12 months thereafter.
5. How Much Do I Want the Extra Perks?
Medicare Advantage offers perks that original Medicare doesn’t, such as coverage for dentures, eyeglasses and fitness benefits, like SilverSneakers. However, you may need to pay extra for some of these perks or accept additional premiums.
Shub Debgupta, founder and CEO at Predict Health, a health care analytics company in Arlington, Virginia, says that some innovative perks to reduce social isolation or improve living conditions that can affect health are becoming more commonplace among Medicare Advantage plans. Specifically, he points out that it’s becoming more common for beneficiaries who are eligible for both Medicare and Medicaid to receive assistance with air conditioning or air filters for their homes.
He also believes that technology support will become a more popular perk offered by Medicare Advantage plans in the near future. With more of our daily life becoming dependent on technology, this could be a very helpful service for seniors.
Financial planning is yet another Medicare Advantage perk that is quickly gaining steam, Debgupta adds.
6. How Do I File an Appeal if Service Coverage Is Denied?
Although many seniors find the perks offered by Medicare Advantage advertisements very appealing, eligible individuals should know that an April 2022 report from the inspector general’s office found that some Medicare Advantage insurance providers denied care or payment for care that would have been covered under original Medicare. In fact, 13% of the instances of denied prior authorization by Medicare Advantage providers met the eligibility requirements of original Medicare.
Debgupta says that it’s vital for people who have a claim denied to understand their rights of appeal.
“When people do appeal or refile, the second refiling acceptance rate is in the 90s. Some of those (denials) are primarily paperwork glitches. The majority of appeals get accepted,” he points out.
7. Does the Medicare Plan Cover Prescription Drugs?
Medicare drug coverage, Part D, helps pay for prescription drugs, though this coverage is optional. It’s important to note that if you don’t sign up for drug coverage when you first enroll in Medicare and you don’t have other coverage at the time, you’ll need to pay a late penalty for the entire time that you are on Medicare.
You can add a Medicare drug plan if you have Medicare Part A and Part B. Alternatively, you can sign up for a Medicare Advantage plan that provides drug coverage.
All plans are required to cover a wide range of commonly prescribed medications. Each plan has a different formulary, which lists what medications are covered. The formulary must include no fewer than two drugs in each of the most commonly prescribed drug classes.
By looking at your medical history, taking stock of your health savings account and reviewing the doctors that you see most often, as well as the medications that you take, you’ll be equipped to make a wise decision when you sign up for or adjust your existing Medicare coverage. When it comes to health care, knowledge truly is power.
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7 Questions to Ask During Medicare Open Enrollment originally appeared on usnews.com
Update 11/14/25: This story was published at an earlier date and has been updated with new information.
