FIRST OF TWO PARTS

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PHILADELPHIA >> Medicare’s fall open enrollment, which runs Oct. 15 to Dec. 7, is an opportunity to review your benefits and make changes for 2025.

Signing up for Medicare or changing plans can seem daunting, but it’s important to make sure you’re enrolled in the best plan for your medical needs. To help make the process easier, The Inquirer has curated a Medicare primer based on questions sent in by readers.

The information is presented in two parts on this Live Well page; it starts today and continues Oct. 29.

Annual open enrollment

Question:What is Medicare’s annual open enrollment?

Answer: A time to review your Medicare coverage — whether you have original Medicare with prescription and supplement plans, or Medicare Advantage. During the fall enrollment period, you can sign up for new coverage or change your plan. You can switch from original Medicare to Medicare Advantage (or vice versa), add a prescription drug or supplement plan to original Medicare coverage, or choose a new Medicare Advantage plan.

Q: Do I need to do anything during the fall enrollment period if I’m happy with my current plan?

A: Yes. Plans may change slightly from one year to the next, so it is important to review your coverage. For instance, the list of medications covered by Medicare Advantage and Part D plans changes every year. Your preferred medication may no longer be covered or the cost may have changed. Also, consider how your health needs have changed.

Medicare 101

Q: What’s the difference between original Medicare and Medicare Advantage?

A: Original Medicare is managed by the federal government and offers coverage for hospital services (Part A) and outpatient services, such as primary care doctors, specialists and routine care (Part B).

Medicare Advantage plans are run by private insurance companies approved by the federal government. These managed-­care plans must cover all the same benefits as original Medicare, though you’ll be limited to their provider networks. They may offer extras, such as dental, vision or hearing services.

Medicare Advantage plans also typically cover prescription medications. People who opt for original Medicare can buy supplemental plans to help cover more costs and a Part D drug plan.

Q:How do I know which plan is right for me?

A: It depends on your medical needs and financial resources.

Original Medicare is accepted by most doctors, which could be important if you need care while traveling out of state. Medicare Advantage plans have provider networks. If you go to an out-of-network doctor or hospital, the visit may not be covered or may cost more.

Use Medicare’s online Plan Finder tool or talk to a volunteer counselor to decide on the best plan for you.

Q: What type of plan should I choose if cost is my biggest concern?

A:It depends. Your total out-of-pocket expense will depend on how the plan you choose covers the services you use most. Both types of plans have a premium for Part B (doctor’s services) — about $175 a month for most people in 2024, as well as a deductible, which was $240 in 2024. The Centers for Medicare & Medicaid Services had not released premium and deductible amounts for 2025 at the time of publication.

Original Medicare beneficiaries pay 20% of the Medicare-approved rate for most doctor services after meeting their deductible. Supplemental plans can help cover some of these expenses.

Copays, coinsurance and deductibles will vary for Medicare Advantage plans, which may charge premiums for its drug coverage and extra services.

Q:Does Medicare restrict which doctors I can see? Can I change doctors?

A: Always ask before making an appointment, but most doctors accept original Medicare.

Medicare Advantage plans have more limited provider networks. Call your plan to ask for a list of in-network providers.

You can switch doctors at any time, but be sure your new doctor is covered by your plan.

Q: Are there any programs to help people pay for Medicare?

A: Yes. People who meet income and asset qualifications may be eligible for one of Medicare’s financial assistance programs.

>> The Qualified Medicare Beneficiary program offers the highest level of assistance, helping pay for Part A and B premiums, deductibles, coinsurance and copays for people with $1,275 or less in monthly income and no more than $9,430 in assets. Income and assets requirements may vary by state and are higher for couples.

>> The Specified Low-Income Medicare Beneficiary helps people who don’t qualify for the QMB program to pay for their Part B premiums.

>> The Qualifying Individual program also helps cover Part B premiums, has an even higher income threshold and is available on a first-come, first-served basis.

>> The Qualified Disabled and Working Individuals program helps cover Part A premiums for people younger than 65 with a disability who are currently working.

The National Council on Aging has a website called BenefitsCheckUp (benefitscheckup.org) to help people research these options.

GLOSSARY OF TERMS

>> Premium: The base cost of the health plan, paid monthly. Regardless of whether you choose original Medicare or Medicare Advantage, you will pay the Part B premium monthly. Most people paid $174.70 a month for the Part B premium in 2024.

>> Deductible: The amount of money you spend out-of-pocket before the plan begins paying a larger share of medical expenses. For 2024, the Part B deductible was $240.

>> Copay: A flat fee you pay for certain services, such as a doctor’s visit or medication.

>> Coinsurance: The portion of a medical bill you must pay even after you meet your deductible. Original Medicare has 20% coinsurance after meeting the deductible, which means you will pay 20% of any medical bill.

>> Drug formulary: The list of prescription medications covered by your plan. Formularies rank medications into tiers, with lower-tier drugs being the preferred and least-expensive options. Higher-tier versions of the same medication will cost more. Health plans frequently switch their preferred choices and may even drop medications from the formulary.

>> In-network: Doctors who accept your health plan are in-network. The vast majority of doctors accept original Medicare. Medicare Advantage plan networks vary.

>> Out-of-network: Doctors who do not accept your health plan are out-of-network. You may have to pay more for their services, or the visit may not be covered at all by your plan.

>> Original or traditional Medicare: A federal health program for people who are 65 or older, or who have a qualifying disability. People who choose original Medicare will enroll in Part B, with choices for optional supplemental and drug plans.

>> Medicare Advantage: Medicare plans sold and operated by private insurers. These federally approved plans must cover all Plan B benefits. They can offer extra services, such as coverage for prescription drugs, and may limit the number of in-network doctors.

>> Part A: Covers hospital visits and medications administered in a hospital setting, such as infused drugs. Most people receive Part A coverage when they turn 65 at no additional cost.

>> Part B: Covers doctor’s visits, labs and other non-hospital services. People who choose original Medicare will enroll in Part B.

>> Part C: Also known as Medicare Advantage.

>> Part D: Prescription drug plans that people who opt for original Medicare can buy.

>> Medigap: Supplemental plans that people who opt for original Medicare can buy to cover out-of-pocket costs, such as copays. Medigap plans do not pay for the Plan B premium.