What Should an Annual Medicare Plan Review Actually Include?
If your Medicare plan worked well this year, you may not see much reason to look at it again. At Capstone Health, we generally agree with the philosophy, “If it’s not broken, don’t fix it.”
But there’s an important second half to that idea: make sure it isn’t broken for next year.
Medicare Advantage and prescription drug plans can change from one year to the next. Costs can change. Prescription coverage can change. Provider networks can change. Benefits you care about may change.
That’s why an annual Medicare review shouldn’t start with an agent asking, “What new benefits do you want?” It should start with a much simpler question:
How did your plan actually work for you this year?
For many Capstone Health clients, a successful annual review ends with us recommending no change at all. The value isn’t in finding something new. It’s knowing that decision was made after actually checking the things that matter instead of assuming next year’s coverage will work the same as this year’s.
Sometimes peace of mind is the best outcome a review can give you.
The First Question We Ask During an Annual Medicare Review
When we sit down with an existing client, one of the first things we want to know is whether they ran into any problems or frustrations with their coverage over the past year.
Was there a doctor they couldn’t see? Did a prescription end up costing more than they expected? Were referrals or authorizations a hassle? Did an unexpected copay show up? Was there a benefit they thought they had but couldn’t actually use the way they expected?
Those answers give us a starting point. If something wasn’t working, we know what we’re trying to fix. If the client is happy, our job becomes figuring out whether the coverage they like will still meet their needs going into the new year.
Medicare plans send an Annual Notice of Change each fall explaining changes in coverage, costs and other plan details that take effect in January. Even someone who had a great year on their plan can face meaningful changes the next year.
A Medicare Review Shouldn’t Start With the Biggest Benefits List
One of the biggest mistakes we see in Medicare plan comparisons is putting benefits ahead of healthcare.
Part B Rebate (Part B Giveback), dental allowances, over-the-counter benefits and, for eligible beneficiaries on certain plans, benefits such as healthy-food or grocery allowances can all have real value. And preferences matter.
If someone currently has a plan with a Part B Giveback that’s important to their budget, we’re not going to casually suggest giving that up. If someone qualifies for a Chronic Condition Special Needs Plan and values a grocery benefit, that’s something we have to factor in.
But the longest list of benefits doesn’t automatically make a plan the best fit. Before we get excited about benefits, we want to know what happens to the client’s doctors and prescriptions.
Doctors Come Before the Extras
Provider networks are one of the most important parts of a Medicare Advantage review. But just asking, “Are all five of your doctors in network?” doesn’t really tell us enough.
We also want to know: Which doctors actually matter to you?
A primary care doctor you’ve trusted for 12 years may be non-negotiable. A cardiologist actively managing a heart condition may be essential. But maybe one of the five names on your doctor list is a dermatologist you saw once for a skin blemish two years ago. Maybe another is the orthopedic surgeon who did your knee replacement four years ago and hasn’t treated you since. Those doctors don’t necessarily carry the same weight.
Changing a less-important provider may sometimes be acceptable if another plan has substantially richer benefits. That doesn’t automatically make the other plan better. A better plan is the one that fits the individual, not the one with more on paper.
There’s a phrase we use often at Capstone:
We can usually find good insurance when good insurance is available. What we can’t guarantee is finding you another good doctor.
That’s why a flashy benefit shouldn’t automatically outweigh a strong relationship with a physician you trust.
If you’re comparing coverage more broadly, our Medicare Annual Review page explains how doctors, prescriptions, plan types and other factors fit together.
Two Plans Can Look Similar on Paper and Work Very Differently in the Real World
This is where Medicare experience becomes hard to reproduce with a comparison chart.
A call-center agent may correctly check a plan’s provider network, formulary, benefits and copays. Someone researching plans on their own may check many of the same boxes. A captive agent may know their company’s plans extremely well, but can only recommend from the plans they’re able to offer. On paper, the comparison may look thorough. In the real world, two plans that look almost identical can operate like polar opposites.
Authorization processes can differ. Referral procedures and turnaround times can differ. Providers may have very different experiences working with different insurance companies. Even issues that don’t immediately affect a beneficiary, like repeated administrative or payment problems experienced by medical practices, can eventually matter if enough providers get frustrated and reconsider their participation with a plan.
These aren’t always things you’ll find on a benefit summary. They’re things you learn through experience with clients, doctors and plans in the local market.
That local experience matters, too. Medicare plans and provider networks vary by market. An agent who regularly works with clients and physicians throughout Tampa Bay may know things about a plan’s network or how it operates locally that aren’t obvious from an online comparison. Finding a Medicare agent who knows your local market can matter just as much as finding someone who represents multiple insurance companies.
This is also part of why being an independent agency means more to us than just collecting as many carrier contracts as possible. Capstone Health may be contracted to represent a carrier without ever intending to recommend it. In some cases, we keep a carrier contract just so the option is there if it truly ends up being the only appropriate solution for a client.
Having the ability to offer a plan and believing it’s the right plan for a particular client are two very different things. Our guide to call-center, captive, independent and self-enrollment options explains why how you choose your Medicare coverage can matter.
What Can Change From One Year to the Next?
Even if you don’t change plans, the plan around you can still change. Depending on your coverage, here’s what’s worth reviewing:
- Premiums and deductibles: A $0-premium Medicare Advantage plan can still have deductibles, copays and coinsurance that change.
- Prescription coverage: A medication may still be covered but move to a different tier, pick up different restrictions or cost more because of a deductible.
- Provider networks: Doctors, specialists, hospitals and other providers can enter or leave networks.
- Copays and coinsurance: What you pay when you actually use healthcare can change even when the monthly premium stays the same.
- Maximum out-of-pocket exposure: Medicare Advantage plans have annual limits for covered Medicare services, and those plan-specific limits can change.
- Extra benefits: Part B Rebates, monthly grocery allowances for eligible beneficiaries on applicable plans, dental, vision, hearing, OTC and other supplemental benefits can all shift from year to year.
“Covered” also doesn’t necessarily mean “affordable.” We’ve seen situations where a client’s prescription technically stayed covered, but a tier or deductible change made the real cost look completely different. That’s the kind of change someone might not notice until they’re standing at the pharmacy counter in January.
The Capstone Health 5 P’s of an Annual Medicare Review
We organize Medicare decisions around what we call the 5 P’s.
1. Price
Price means more than the monthly premium. We look at premiums, deductibles, copays, coinsurance and the potential out-of-pocket costs tied to the healthcare a client is actually likely to use.
A $0 premium doesn’t mean $0 healthcare.
2. Physicians
We verify the doctors, specialists, hospitals and medical groups that matter to the client. Just as importantly, we figure out which physicians matter most.
Keeping every name on an old doctor list isn’t necessarily more important than finding coverage that fits the client’s current healthcare needs.
3. Preferences
Preferences help us understand how someone wants their Medicare coverage to actually work.
Does the client prefer the larger network and flexibility of a PPO, or would they prefer lower copays and extra benefits that may be available through an HMO? Is having no referrals more important than lower copays? Do they travel a lot, or mostly stay within Tampa Bay? Is a Part B Giveback important to their monthly budget? Do they care about particular dental, vision, OTC or other supplemental benefits? Read more on our Medicare Advantage Deep Dive page.
There’s no one correct set of preferences. The point is understanding which ones matter to that person before we start comparing plans.
If you’re still learning how the different parts of Medicare fit together, Medicare 101 is a good place to start.
4. Prescriptions
We review the client’s medications, coverage, tiers, deductibles, restrictions and pharmacy options.
A prescription showing up on the formulary is really just the beginning of the conversation. We also need to know what getting that medication is likely to cost and whether any restrictions could get in the way of access.
Sometimes a prescription discount service such as GoodRx may offer another cash-price option. For example, if one medication isn’t covered by a plan that otherwise checks all the important boxes, it can be a mistake to switch to an entirely different plan just because it covers that $20 medication if doing so means paying hundreds more elsewhere.
One prescription should be weighed as part of the client’s whole healthcare and coverage picture, not on its own.
5. Prior Coverage
What Prior Coverage means changes depending on where someone is in their Medicare journey.
For someone turning 65, we may look at their employer or group coverage and ask what worked well, what they valued and what they’re used to.
During an annual Medicare review, Prior Coverage means looking at how the client’s existing Medicare plan actually performed and comparing that experience with the options available for the coming year.
What worked? What didn’t? What’s changing?
The 5 P’s give us a consistent framework without assuming every Medicare beneficiary should land on the same answer.
A Successful Annual Review Doesn’t Have to End With a Plan Change
This part is important. An annual Medicare review isn’t successful because an agent found something new to sell. Most of the time, we’re perfectly comfortable telling an existing client to stay on their current plan when the review shows it’s still a good fit.
If it’s not broken, don’t fix it.
But we don’t reach that conclusion by ignoring the plan for another year. We verify the important physicians. We check prescriptions. We review upcoming costs and benefits. We look at what the client actually values and how their current coverage performed.
If everything still lines up, staying exactly where you are may be the right call. The difference is, now you know that for sure.
Peace of mind is priceless.
Why Independence and Experience Both Matter
An independent Medicare agent can compare plans from multiple insurance companies the agency represents rather than being limited to one carrier. But independence alone isn’t enough.
Experience is what helps an agent recognize that a plan can look great on paper and still cause real frustrations in practice. Local experience matters too.
Provider participation, medical groups and plan availability can differ from one Tampa Bay community to the next. An agent who regularly works with local Medicare beneficiaries and physician offices tends to run into issues that just aren’t visible on a national comparison screen.
Capstone Health is a local, family-owned independent Medicare agency with an office at 7206 Massachusetts Ave, New Port Richey, FL 34653. Our clients also have access to administrative support and year-round service after enrollment. Need to know which dentists accept your plan, where to get glasses, or whether a medical bill looks right? Call us or stop in.
We don’t think the agent-client relationship should disappear once enrollment is done. Part of our job is proactively reviewing coverage so our clients don’t have to figure everything out on their own. And if a change doesn’t offer a real advantage, we’re comfortable saying so.
What Happens If You Skip Your Medicare Review?
Often, nothing happens right away. That’s exactly why skipping a review can feel harmless.
The problem tends to show up in January instead. You get to the pharmacy and find out a familiar prescription costs a lot more. You schedule an appointment and discover something changed with a provider or network. You get care and realize the copay or deductible isn’t what you were expecting. Or you find out a benefit you counted on changed for the new year.
By then, the enrollment window you could have used in the fall may have already passed.
Medicare Open Enrollment runs from October 15 through December 7 each year, with changes generally taking effect January 1.
The point of an annual review isn’t to assume something bad is going to happen. It’s to catch meaningful changes before they turn into surprises.
Frequently Asked Questions About Annual Medicare Reviews
Do I have to change plans after an annual Medicare review?
No. A review is meant to check whether your current coverage still fits. In many cases, staying on the existing plan ends up being the right call.
When should I review my Medicare coverage?
Fall is especially important because Medicare Open Enrollment runs from October 15 through December 7, and plans communicate their changes for the coming year before that window opens. A review can also make sense at other times when health needs, prescriptions, providers, residence or other circumstances change.
What should I bring to an annual Medicare review?
Having your current plan information, medication list, preferred pharmacies, doctor list and Annual Notice of Change on hand makes the review go a lot smoother. You may also need your Medicare card if we get into enrollment or coverage details.
What if my doctor won’t accept my Medicare Advantage plan next year?
Don’t assume one network change automatically means you should switch plans. First figure out how important that provider actually is to your ongoing care, what alternatives exist, what your plan options look like and whether you’re in an enrollment period that allows a change.
Does Capstone Health charge for an annual Medicare plan review?
No. Capstone Health doesn’t charge Medicare beneficiaries a fee for an annual plan review. Insurance carriers may compensate the agency when a beneficiary enrolls in a plan through Capstone Health. There’s no obligation to change plans simply because you completed a review.
A Note From Will
Our job at Capstone Health is to proactively do that homework with our clients, recommend a change when there’s a real advantage to it and be here throughout the year whenever questions come up. It’s the same approach I’ve taken helping Medicare beneficiaries for more than 20 years. I’m a firm believer in “if it’s not broken, don’t fix it.” But I don’t want a client finding out in January that something was broken and nobody checked.
Most annual reviews don’t need to end in some dramatic change. A lot of the time, the best result is simply confirming that your doctors still work, your prescriptions still make sense, the benefits you care about are still there and your current plan is still a good fit. That’s peace of mind.
Ready for Your Annual Medicare Review?
A good review isn’t about finding the plan with the longest benefits list. It’s about figuring out whether your coverage still fits your doctors, prescriptions, preferences and healthcare needs for the coming year.