Question; I have a new serious medical diagnosis, and some related procedures scheduled. Should I be adjusting my Medicare insurance coverage?

Answer; When individuals are enrolled in Medicare Part A & B, they are very protected. Original Medicare and the insurance products that accompany i, can work well together and can be very comprehensive. Once enrolled in Medicare there are very few situation where pre-existing limitations would come up.

Original Medicare (Medicare Part A & B) is a comprehensive national insurance product that allows you to go to the doctor when and where you like. Your potential medical cost liability is dependent on the additional products you added onto your Original Medicare. There are currently two main ways you can go to get additional coverage: Medicare Advantage (or Part C of Medicare), or a Medicare Supplement Plan or “Medigap” Plan.

With a Medicare Supplement Plan, you can use this plan in addition to original Medicare. The Supplement would pick up all or most of those deductible and co-pays that would be left behind with Original Medicare alone, depending on the plan you enroll in. So original Medicare plus a Medicare Supplement Plan can cover almost all your costs.

The other options is a Medicare Advantage Plan. Most individuals who have Original Medicare chose to enroll in a Medicare Advantage Plan in recent years. With a Medicare Advantage (MA) Plan you also have useful coverage, but your MA Plan is the ONLY health insurance you have to cover your claims (Medicare doesn’t pay the claims). The MA Plans have co-pays and deductibles that you are responsible for. Each plan has a Maximum Out of Pocket (MOOP) expenses you will pay, as long as you use participating providers for the plan. In 2026 the MOOP for HMOs $9,250, and the MOOP for PPOs can be as much as $14,750. This annual amount, is a LOT of money, but when you think of how many hundreds of thousands of dollars some procedures can cost, it is a pretty low cost share.

You don’t want to spend that much year after year of course. But it is important to remember that in some situations, you can CHANGE your insurance. This can be especially important if what you have currently doesn’t fit your situation anymore.

Each year there are opportunities to change your insurance, these are called Annual Enrollment Periods. There are two, October 15 thru December 7 is the AEP where everyone with Medicare can make a different selection to begin January 1. The second is January 1 to March 31, and this is the Medicare Advantage AEP. This AEP is available to all Medicare eligible individuals who are enrolled into a Medicare Advantage Plan. During this time, they can make one change to anything else they wish. The change will be effective the first of the month after they make the change (Feb 1, March 1 or April 1).

Outside of these Open Enrollment Periods, you can only change your coverage if you qualify for a Special Enrollment Period (SEP). The SEPs are special circumstances or situations that allow you to change your mind and enroll in a different insurance product. There are 21 different SEPs that you could qualify for when enrolled in Medicare.

These SEP’s may give you the freedom to make a new choice when and if that becomes necessary. I cannot guarantee everyone can always change their insurance coverage immediately. But I can say you could have some opportunities to change your choice now and at the very least once annually, during October 15th to December 7th. Even in situations where I have worked with an individual who may not have the perfect plan right now, we can breathe easy knowing there could be SEPs to use or AEP each year to find a better more appropriate plan for next year.

The list of 21 SEPs are for pretty specific situations, but one of these could allow you to change your insurance plan. The most commonly used SEPs are; having EPIC (the New York State Pharmacy Assistance Product) or leaving a group plan (like an employer group plan or retiree group plan), or going into or out of a Skilled Nursing Facility (like for rehab after a stroke, joint replacement or fracture), or moving to a new location, (different county or state). However that is only four of the 21 available.

If your situation has changed because of illness, or other circumstances and you want to know what can be done to improve your situation, please call and ask for help! If you are not sick, it’s important to know that you can change your coverage in the future if you need to. Your insurance can be adjusted to find a better fit for what you need.

When you have Medicare you have great insurance, but sometimes the choice we made for this year needs to change and it is worth evaluating if that change is possible and warranted.

Janell Sluga is a Geriatric Care Manager helping seniors in our community access services and insurance. To reach her, please email editorial@post-journal.com.