Understanding Medicare Open Enrollment: What You Need to Know

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Every year, Medicare’s open enrollment period offers a short window of opportunity to make changes that can have a lasting impact on your healthcare—and your wallet. Yet many people approach it unsure of where to begin, what to look for, or how to make decisions that truly work for them.

The independent health insurance agents at Stith & Associates Health Insurance Agency, Inc.  talk to individuals and families all the time who feel overwhelmed by the process. This guide is here to help simplify what can feel like a complex task. Whether you’re enrolling for the first time or reviewing your current plan, here’s what you should know to make the most of this crucial period.

What Is Medicare Open Enrollment?

Medicare Open Enrollment runs from October 15 to December 7 each year. This is the time when individuals already enrolled in Medicare can:

• Switch from Original Medicare (Part A and B) to a Medicare Advantage (Part C) plan—or vice versa
  
  

• Change from one Medicare Advantage plan to another
  
  

• Join, switch, or drop a Part D prescription drug plan
  
  

These changes take effect on January 1 of the following year.

Why This Period Matters

Life changes—and so do healthcare needs. Maybe your prescription list has grown. Perhaps your doctor is no longer in-network. Or, maybe a better plan option is available for the upcoming year with lower premiums, better coverage or fewer restrictions.

Open enrollment allows you to reevaluate your current situation and adjust your coverage accordingly. But the window is brief, and decisions made during this time can shape your healthcare for the next 12 months.

What You Should Review

Before making any changes, take a close look at your current plan. Consider:

• Monthly costs: Are your premiums and out-of-pocket costs manageable?
  
  

• Prescription coverage: Are your medications still covered under your current plan’s formulary?
  
  

• Provider network: Are your doctors and preferred hospitals still in-network?
  
  

• New benefits: Are there any added perks (like dental, hearing, vision, or gym memberships) you’d like to take advantage of?
  
  

Even if you're happy with your plan, it's a good idea to confirm nothing has changed in the plan’s structure for the upcoming year. Carriers adjust coverage all the time—and it's up to you to catch those changes before they affect your care or your budget.

Common Mistakes to Avoid

One of the biggest mistakes people make is simply doing nothing. Assuming your current plan is “good enough” without reviewing the updates for the next year can be costly. Drug plans, in particular, tend to update their formularies, and a drug you rely on this year might cost significantly more in the next.

Another common issue is choosing a plan based solely on premium costs. While low premiums might seem appealing, they can sometimes mean higher deductibles, narrower networks, or fewer prescription options. It’s essential to look at the total picture.

How to Get Help Making the Right Choice

You don’t have to figure this all out on your own. Medicare’s official website offers plan comparison tools, but navigating them can still be a bit tricky. Speaking with a licensed independent agent—someone who understands both the national options and local provider networks—can give you a clearer sense of what makes the most sense for your personal health situation.

Agents can also help you:

• Compare Part D drug plans based on your current prescriptions
  
  

• Find Medicare Advantage plans that include dental, vision or other added benefits
  
  

• Understand the differences between Medigap (supplemental) coverage and Advantage plans
  
  

• Make sure your preferred doctors are covered under any new plan you consider

Don’t Wait Until the Last Minute

Although Medicare Open Enrollment stretches over several weeks, it’s best not to wait until the final days. Reviewing your plan, gathering necessary information, and asking questions takes time. And with deadlines set in stone, procrastination can leave you stuck with a plan that no longer fits your needs.

How to Make the Most of Medicare Open Enrollment

Although the open enrollment period runs through early December, acting early is strongly recommended. Reviewing plan changes, comparing coverage options, and verifying provider networks can take time—especially when prescription coverage or out-of-pocket costs are involved.

Waiting until the last minute increases the risk of missing important plan changes or overlooking better alternatives. Early preparation allows for a smoother transition into the new year with confidence in the selected coverage.

Choosing the right Medicare plan is not just about minimizing costs—it's about finding a balance between comprehensive benefits, access to preferred providers, and long-term peace of mind.

For those who need guidance, working with a licensed independent insurance agent can provide clarity during the decision-making process. With support from someone familiar with both national and local plan options, enrollees can avoid guesswork and move forward knowing they’ve made an informed choice.

Top 10 Questions to Ask Before Choosing a Health Insurance Plan

Choosing a health insurance plan shouldn’t feel like decoding a secret language—but for many, it does.

The terminology is confusing. The options are overwhelming. And the consequences of choosing the wrong plan can be both financial and personal. Whether you’re navigating open enrollment, exploring options for the first time, or making a change due to life circumstances, one thing is certain: asking the right questions matters.

In this guide, we’ll explore the 10 most important questions you should ask before committing to a health insurance plan. Armed with these, you’ll be better equipped to make a confident and informed decision.

Why Asking the Right Questions Matters

In 2023, the average healthcare spending per person in the U.S. reached $14,570. For most Americans, health insurance is a major financial decision—one that impacts not just their wallets, but their access to care, peace of mind, and long-term well-being.

And coverage isn’t limited to just traditional health insurance anymore. When choosing a plan, you may encounter options such as:

• Health insurance
  
  

• Dental insurance
  
  

• Vision insurance
  
  

• Life insurance
  
  

• Medicare and supplemental Medicare plans
  
  

Understanding what each plan includes, and how it aligns with your needs, is key.

1. What Type of Plan Is It (HMO, PPO, EPO, POS)?

The type of plan determines how you access care and how much flexibility you have in choosing providers.

For example, an HMO usually offers lower premiums but limits you to a specific network of doctors and requires referrals to see specialists. PPOs, on the other hand, give you more freedom to see out-of-network providers but often come with higher costs.

EPOs and POS plans each have their own combinations of access and referral requirements. Consider your lifestyle, how often you visit specialists, and whether you have trusted providers you'd prefer to keep seeing.

2. What Does the Plan Actually Cover?

Not all health plans cover the same services. While most plans include essential benefits like preventive care, hospitalization, maternity, mental health, and prescription drugs, the details can vary.

Some plans include extra services like acupuncture, chiropractic care, or fertility treatments. Others may exclude certain therapies or limit the number of visits. It’s important to review the summary of benefits and identify whether your needs—such as regular physical therapy or mental health counseling—are covered.

3. Are My Doctors and Hospitals In-Network?

If you have a preferred doctor or nearby hospital you trust, make sure they’re considered in-network. Out-of-network care often comes with significantly higher out-of-pocket costs—or might not be covered at all.

Double-check provider directories or call the provider’s office directly. Don’t rely solely on search tools that may be out of date.

4. What Will I Pay—Beyond Just the Premium?

It’s easy to focus on the monthly premium, but that’s only one part of the cost equation. Ask about:

• Deductibles: How much you must pay before your plan begins to cover services
  
  

• Copays and coinsurance: Your share of costs for visits, prescriptions, and procedures
  
  

• Out-of-pocket maximums: The cap on your yearly expenses
  
  

Consider a scenario: a plan with low premiums might have a high deductible, meaning you'll pay thousands before coverage kicks in. Sometimes, paying a slightly higher premium results in lower overall spending—especially if you use your insurance regularly.

5. Are My Prescriptions Covered?

Your plan may not cover every medication. Each insurer maintains a formulary—a list of approved drugs, grouped by tiers. Tier 1 drugs usually have lower copays, while higher-tier or specialty drugs can be costly or require prior approval.

Review the plan’s drug list to see if your medications are included. If not, you may need to request an exception or consider switching to a different plan.

6. Do I Need Referrals to See a Specialist?

Some plans, like HMOs, require a referral from your primary care doctor before seeing a specialist. Others, such as PPOs, allow you to schedule directly.

If you manage a chronic condition or anticipate needing specialty care (like dermatology or physical therapy), this access can affect both cost and convenience. Think about how often you might need specialist services in the coming year.

7. How Is Emergency and Urgent Care Covered?

Emergency situations are unpredictable, and coverage can be tricky—especially when you’re away from home. Most plans will cover emergency care at any hospital, but follow-up care or post-emergency services may not be fully covered if out-of-network.

If you travel frequently, make sure your plan offers flexibility for urgent or emergency care across state lines.

8. Does the Plan Include Extras Like Dental, Vision, or Wellness Programs?

Many people overlook ancillary benefits that could save them money and improve their quality of life. Some plans bundle or offer discounts on:

• Routine dental exams and cleanings
  
  

• Vision screenings, glasses, and contacts
  
  

• Gym memberships or weight loss support
  
  

• Telehealth services
  
  

Even if these aren’t deal-breakers, they can add extra value—especially for families, older adults, or those managing lifestyle-related health issues.

9. How Does the Plan Treat Pre-Existing Conditions?

Under current federal law, insurance companies cannot deny coverage or charge more based on pre-existing conditions. However, that doesn’t mean every plan offers the same level of care or access to specialists for chronic conditions.

If you have ongoing health needs, look closely at whether your providers, medications, and necessary services are accessible and affordable under the plan.

10. What’s the Insurance Company’s Reputation Like?

Even the best coverage can be frustrating if the insurer has poor customer service or makes it difficult to file claims.

Look for online reviews, Better Business Bureau ratings, or customer satisfaction surveys. A responsive insurer can make a big difference when you're dealing with complex billing, denied claims, or unexpected changes.

Case Example: Making the Right Choice

Let’s say Jane, a freelance graphic designer in South Jersey, takes two medications, sees a therapist monthly, and travels frequently for work.

• An HMO plan would save her money on premiums but limit her ability to access her therapist and require referrals.
  
  

• A PPO plan would cost more upfront but allow her to continue with her therapist and provide nationwide coverage when she travels.
  
  

For Jane, the higher cost was worth the flexibility and continuity of care. Asking the right questions helped her avoid switching doctors mid-year or paying hundreds out-of-pocket.

Bonus: Tips for Open Enrollment Season

Open enrollment is your opportunity to make changes—don’t let it pass you by. Here are a few ways to make the most of it:

• Make a list of your current doctors, prescriptions, and routine services
  
  

• Estimate your expected medical needs for the year ahead
  
  

• Use comparison tools to review multiple plans side-by-side
  
  

• Consider bundling with dental or vision plans
  
  

• Talk to a licensed health insurance agent for free advice
  
  

Conclusion: Ask Smarter, Choose Better

Choosing the right health insurance plan isn’t just about picking the cheapest premium. It’s about understanding how the plan fits into your life, your health needs, and your financial situation.

By asking the 10 questions above, you’re not just checking boxes—you’re taking control of your care.

Need help comparing plans or understanding your options?
Contact our team for personalized guidance on health, dental, vision, life insurance, and Medicare plans in Greater Philadelphia and South Jersey.