As Medicare open enrollment begins on Oct. 15 (and continues through Dec. 7), millions of older Americans face the dilemma of choosing between traditional Medicare and Medicare Advantage. This decision can significantly impact access to care, financial stability and overall health. Understanding these options is more important than ever, with major changes to Medicare on the horizon.

In 2025, several reforms are taking place that will make Medicare more affordable for many beneficiaries. One of the most notable is a new $2,000 annual cap on out-of-pocket prescription drug costs for those enrolled in Medicare Part D; the previous out-of-pocket limit was $8,000. This is a positive change for the many seniors who struggle to pay for their medications. Other reforms include expanded financial assistance for low-income individuals and price negotiations for some high-cost drugs, which should help lower prices across the board.

Traditional Medicare, with its nationwide network of participating providers, enables enrollees to see any doctor or specialist who accepts Medicare. It also generally avoids the hassle of pre-authorizations, simplifying access to care without associated delays. However, out-of-pocket costs can add up quickly, as there’s no cap on expenses, such as deductibles and coinsurance, for things other than medications. Many beneficiaries opt to cover these additional costs by purchasing supplemental insurance, known as Medigap policies.

Medicare Advantage, offered by private insurance carriers, bundles Medicare Parts A, B and often Part D into a single plan. Medicare Advantage plans may offer additional benefits, such as dental and vision coverage. However, they typically have restricted networks of providers. Receiving care outside of those networks can lead to higher costs or even denial of payment. Nearly all Medicare Advantage plans require pre-authorization for at least some services, which can delay or deny access to necessary care.

There are specific times when changes can be made in Medicare or Medicare Advantage coverage. The Medicare open enrollment period is the time to switch between traditional Medicare and Medicare Advantage or to change to a different type of Medicare Advantage plan. There is a separate Medicare Advantage open enrollment period from Jan. 1 to March 31, when it is possible to change from Medicare Advantage to traditional Medicare or change from one Medicare Advantage plan to another. Ironically, however, it is generally NOT possible to change from traditional Medicare to Medicare Advantage during Medicare Advantage Open Enrollment. For more details, go to Medicare.gov.

In summary, while the new Medicare policy changes are positive ones, they do not necessarily make the decision-making process any easier. The choice between traditional Medicare and Medicare Advantage remains complex, with each option offering distinct advantages and disadvantages. Each person should consider their particular needs and preferences, do their research, and make the best choice for their situation.

For more Medicare information, visit AsclepiusInitiative.org/medicare.