Medigap Plan Letters Explained: A vs. B vs. F vs. G vs. N (2027 Comparison)

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August 16, 2026

Compare Medigap Plans Now →

Medigap Plans Explained 2027: Complete Guide to Medicare Supplement Insurance

2027 Quick Facts: Medigap plans are standardized by letter (A–N) in most states, sold by private insurers, and do not change year to year the way Medicare Advantage plans do. Your Medigap premium can change annually, but your benefits stay the same as long as you keep paying.

If you’re turning 65, retiring, or simply tired of unpredictable Medicare bills, you’ve probably run into the term “Medigap” more than once this year. With Medicare Open Enrollment approaching, insurance mailers, TV ads, and well-meaning relatives are all pushing opinions about Medigap, Medicare Advantage, and which one is “better.” This guide cuts through the noise and explains exactly what Medigap is, how it works in 2027, what it costs, and how to decide if it’s right for you.

What Is Medigap Insurance?

Medigap, formally known as Medicare Supplement Insurance, is a private insurance policy designed to work alongside Original Medicare (Part A and Part B). Medicare itself only pays a percentage of most covered services — typically 80% for Part B services — which leaves beneficiaries responsible for the remaining coinsurance, copayments, and deductibles. Medigap policies are built specifically to pick up some or all of that remaining “gap,” which is where the name comes from.

Medigap is sold exclusively by private insurance companies, but every plan must follow federal and state rules that standardize the benefits. That’s a critical distinction from Medicare Advantage, where benefits vary widely by carrier and even by zip code. A Medigap Plan G from one company, for example, covers exactly the same core benefits as a Plan G from another company — the only real differences are price, customer service, and financial stability of the insurer.

How Medigap Works With Original Medicare

Medigap only works alongside Original Medicare — it cannot be paired with a Medicare Advantage plan. Here’s the basic flow when you have Medicare plus Medigap:

You see any doctor or hospital nationwide that accepts Medicare (no networks or referrals).
Medicare pays its share of the approved amount first.
Your Medigap insurer automatically pays some or all of the remaining balance, depending on your plan letter.
In many cases, you owe little to nothing out of pocket for covered services.

Because Medigap has no provider networks, it’s especially popular with retirees who travel, split time between two states, or simply want the freedom to see specialists without a referral. For a deeper look at how this compares with the managed-care model, see our breakdown of Medigap vs. Medicare Advantage costs over 10 years.

The Medigap Plan Letters (A Through N)

In most states, Medigap plans are standardized into lettered categories: A, B, D, G, K, L, M, and N (Plans C and F are largely closed to people newly eligible for Medicare on or after January 1, 2020). Each letter offers a fixed set of benefits set by the federal government — insurers cannot add or remove benefits from a lettered plan, they can only compete on price and service.

Plan	Popularity	Best For
Plan G	Most popular for new enrollees	Near-total coverage; only Part B deductible left unpaid
Plan N	Fast-growing, lower premium	Budget-conscious shoppers willing to pay small copays
Plan A	Basic tier	Minimal coverage, lowest premiums
Plan F	Closed to new enrollees since 2020	Existing policyholders only (first eligible before 2020)
Plan K / L	Cost-sharing plans	Lower premiums with an annual out-of-pocket limit

For a full side-by-side comparison of what each letter actually covers, read our detailed breakdown: Medigap Plan Letters Explained: A vs. B vs. F vs. G vs. N. If you’re deciding between the two most popular options, we also have a focused comparison of Plan G vs. Plan N.

When You Can Enroll in Medigap

Unlike Medicare Advantage and Part D, Medigap does not run on the October 15–December 7 Annual Enrollment Period. Instead, Medigap has its own one-time 6-month Medigap Open Enrollment Period that begins the month you turn 65 and are enrolled in Part B. During this window, insurers must sell you any Medigap policy they offer, at the best available price, regardless of your health history.

Outside that window, insurers in most states can use medical underwriting to deny coverage or charge more based on pre-existing conditions — unless you qualify for a Guaranteed Issue Right. These two topics are complex enough that we’ve dedicated full guides to each:

What Medigap Costs in 2027

Medigap premiums vary significantly by state, age, gender, tobacco use, and pricing method (community-rated, issue-age-rated, or attained-age-rated). Nationally, Plan G premiums have generally ranged from roughly $120 to $300+ per month depending on location and age, while Plan N tends to run lower. Because pricing differs so much by state, we’ve built a dedicated state-by-state breakdown: How Much Does Medigap Cost in 2027? State-by-State Premium Guide.

💡 Tip: Because all Plan G policies cover identical benefits, shopping by price alone — while confirming the carrier’s financial strength rating — is a legitimate and common strategy for lowering your premium without losing coverage.

Medigap vs. Medicare Advantage

This is the single biggest decision most new Medicare beneficiaries face. Medigap generally means higher monthly premiums but very low or no out-of-pocket costs at the point of care, plus nationwide provider access. Medicare Advantage generally means low or $0 premiums but network restrictions, referrals, and variable out-of-pocket costs that can add up quickly during a serious illness. We go deep on the 10-year cost math in our companion article, Medigap vs. Medicare Advantage: Which Costs Less Over 10 Years?

How to Choose a Medigap Plan

Start with your health needs. Frequent specialist visits or a chronic condition often favor richer plans like G.
Compare Plan G and Plan N carefully. Plan N has a lower premium but adds small copays — our Plan G vs. Plan N comparison shows the break-even math.
Check carrier financial ratings (A.M. Best, S&P) since you may hold this policy for decades.
Time your enrollment around your 6-month Open Enrollment window whenever possible to avoid underwriting.
Re-shop periodically. Because benefits are standardized, you can often switch carriers for the same Plan G coverage at a lower price — see Switching Medigap Plans.

Ready to compare Medigap rates from top-rated carriers in your area?

Frequently Asked Questions

What is Medigap insurance?: Medigap, also called Medicare Supplement Insurance, is a private policy that helps pay the out-of-pocket costs — copayments, coinsurance, and deductibles — that Original Medicare leaves behind.
Can I have Medigap and Medicare Advantage at the same time?: No. Insurers cannot legally sell you a Medigap policy while you’re enrolled in a Medicare Advantage plan, except when you’re actively switching back to Original Medicare.
Does Medigap cover prescription drugs?: No. Current Medigap policies do not include drug coverage. You’ll need a standalone Medicare Part D plan alongside your Medigap policy.

Medicare Open Enrollment 2027: The Complete Guide

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August 8, 2026

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Medicare Open Enrollment 2027 The Complete Guide — Medicare Open Enrollment 2027: The Complete Guide

Everything you need to know about Medicare Open Enrollment for 2027 coverage: key dates, what you can change, deadlines, and how to compare plans before December 7.

By the SeniorAffair.com Medicare Team · Reviewed for accuracy against CMS.gov and Medicare.gov

Medicare Open Enrollment—officially the Annual Enrollment Period (AEP)—runs from October 15 to December 7, 2026. It is the once-a-year window when anyone with Medicare can review their current coverage and switch to a different Medicare Advantage plan, Part D drug plan, or move between Original Medicare and Medicare Advantage. Any changes you make take effect on January 1, 2027.

Article Contents

This guide walks through everything that happens during those seven weeks: who the window applies to, what you’re allowed to change, how it’s different from the other Medicare enrollment periods, and the concrete steps to take before the December 7 deadline.

Quick answer: If you already have Medicare, you don’t have to do anything during open enrollment—your current plan will continue automatically if it’s still offered. But because plans change their premiums, drug formularies, and provider networks every single year, skipping the review is one of the most common ways beneficiaries end up overpaying in the new year.

What Is Medicare Open Enrollment (AEP)?

The Annual Enrollment Period is a federally set window that applies to nearly everyone already enrolled in Medicare. During AEP, Medicare health and drug plans are allowed to change their costs, covered providers, and pharmacy networks for the upcoming year—and CMS requires plans to notify members of those changes through an Annual Notice of Change (ANOC) letter, typically mailed by September 30. AEP is your annual chance to react to those changes or simply shop around to see if a better-fitting plan is available in your area.

AEP is sometimes called the “Annual Election Period” or “Fall Open Enrollment”—all three names refer to the same October 15–December 7 window.

Key Dates for the 2026–2027 Enrollment Cycle

Date	What Happens
By September 30, 2026	Medicare Advantage and Part D plans mail their Annual Notice of Change (ANOC) letters
October 15, 2026	Open Enrollment (AEP) begins
December 7, 2026	Open Enrollment (AEP) ends — last day to submit a change
January 1, 2027	All AEP changes take effect
January 1 – March 31, 2027	Medicare Advantage Open Enrollment Period (a second, more limited window for MA members only)

Curious what’s changing with your specific plan for 2027? See side-by-side Medicare Advantage, Part D, and Medigap options in your ZIP code.

Who Does Open Enrollment Apply To?

AEP applies to anyone already enrolled in Medicare Part A and/or Part B, regardless of whether you currently have Original Medicare, a Medicare Advantage plan, or a standalone Part D drug plan. It is separate from your Initial Enrollment Period (the seven-month window around your 65th birthday) and separate from the General Enrollment Period (January 1–March 31, for people who missed signing up for Part A/B in the first place).

What You Can Change During AEP

Switch from Original Medicare to a Medicare Advantage plan
Switch from a Medicare Advantage plan back to Original Medicare
Switch from one Medicare Advantage plan to another
Join a Medicare Advantage plan for the first time
Join, switch, or drop a standalone Part D prescription drug plan

For a full breakdown of the Advantage-vs-Original decision, see Medicare Advantage vs. Original Medicare: How to Decide. If you already know you want to switch Medicare Advantage plans, the step-by-step process is covered in How to Switch Medicare Advantage Plans During Open Enrollment.

AEP vs. Other Medicare Enrollment Periods

Period	When	Who It’s For
Annual Enrollment Period (AEP)	Oct 15 – Dec 7	Anyone with Medicare — broadest set of changes allowed
Medicare Advantage Open Enrollment Period	Jan 1 – Mar 31	Only people already in a Medicare Advantage plan; one plan switch or a return to Original Medicare
General Enrollment Period	Jan 1 – Mar 31	People who missed their Initial Enrollment Period and need to sign up for Part A/B
Special Enrollment Periods (SEPs)	Triggered by a qualifying life event	People who moved, lost employer coverage, qualify for Medicaid, and other specific situations

Missed the deadline or think you might qualify for a SEP instead? See Medicare Special Enrollment Periods: Do You Qualify? and Medicare Open Enrollment Deadlines and Penalties.

Step-by-Step: How to Prepare for Open Enrollment

Read your ANOC letter. This arrives by the end of September and lists exactly what’s changing about your current plan for next year—premium, deductible, drug tiers, and provider network.
List your current prescriptions and doctors. Plan formularies and networks change yearly; confirm your medications are still covered and your providers are still in-network.
Check the plan’s star rating. CMS rates Medicare Advantage and Part D plans from 1 to 5 stars on quality and member experience—see Medicare Advantage Star Ratings Explained.
Compare total annual cost, not just premium. A $0 premium plan with high copays can cost more than a plan with a modest premium. See Medicare Costs in 2027: Premiums, Deductibles, and Limits for a full cost breakdown.
Decide between Medigap and Medicare Advantage if you’re considering Original Medicare—the cost tradeoffs are different for everyone. Compare them in Medigap vs. Medicare Advantage: Which Costs Less?.
Submit your change before December 7. Changes can be made online at Medicare.gov, by phone, or through a licensed agent.

What Happens If You Do Nothing?

If your current Medicare Advantage or Part D plan is still being offered in your area next year, your coverage rolls over automatically—you don’t have to re-enroll. The risk isn’t losing coverage; it’s staying in a plan whose costs or network no longer fit your needs. Because formularies and provider networks are reset every January 1, a plan that worked well this year can look very different in 2027.

Not sure if a lower-premium plan is actually the better deal? Compare total estimated annual cost across plans near you.

Compare Total Costs →

2026 Costs as a Starting Point

CMS typically announces final 2027 premiums, deductibles, and the Part D out-of-pocket cap in the fall, closer to the start of AEP. As of the 2026 plan year, the standard Part B premium is $202.90/month and the Part D out-of-pocket cap is $2,100. See the full, regularly updated breakdown in Medicare Costs in 2027: Premiums, Deductibles, and Limits.

Use our printable 10-question Open Enrollment checklist to walk through your review in about 20 minutes.

Why Medicare Plans Change Every Year

It surprises a lot of people that a Medicare Advantage or Part D plan can look completely different from one January to the next, even under the same plan name. Insurers renegotiate contracts with hospitals, doctors, and pharmacy networks annually. Drug manufacturers change list prices, which changes how a plan’s formulary tiers are structured. And CMS itself adjusts the underlying payment rates it pays insurers, which trickles down into premiums and supplemental benefits like dental, vision, and over-the-counter allowances. None of this is optional or announced mid-year—it all resets on January 1, which is exactly why the fall review window exists.

Using the Medicare Plan Finder

Medicare.gov’s Plan Finder tool lets you enter your ZIP code, current medications, and preferred pharmacy to see every Medicare Advantage and Part D plan available in your area, ranked by estimated annual cost. It’s free, doesn’t require creating an account to browse, and is the same tool licensed agents use behind the scenes. A few tips that make it more useful:

Enter every prescription exactly as it’s dosed—generic vs. brand name can change which tier a drug falls into.
Add your preferred pharmacy, since some plans offer lower copays at preferred pharmacy networks.
Sort by “estimated annual cost,” not premium alone, so copays and deductibles are factored in.
Re-run the search even if you’re happy with your plan—new plans enter the market every year and older ones sometimes exit.

Helping a Parent or Spouse Through Open Enrollment

If you’re reviewing coverage on behalf of a parent or spouse, you’ll need their Medicare number, a list of their current prescriptions with dosages, and a list of the doctors and specialists they see regularly. You can call 1-800-MEDICARE together, or a licensed agent can walk through options over the phone in about 20-30 minutes. Because Medicare Advantage and Part D plans require the beneficiary’s own consent to enroll (or a documented authorized representative), it’s worth setting aside time to do this together rather than trying to make the decision unilaterally.

Common Open Enrollment Mistakes to Avoid

Comparing premiums only. A low-premium plan with a high deductible and narrow specialist network can cost far more over a full year than a plan with a higher monthly premium.
Assuming your doctor is still in-network. Networks are rebuilt annually. Confirm directly with the plan or the provider’s office, not just last year’s card.
Ignoring the star rating. Plans with consistently low ratings tend to have more customer service and claims issues—see Medicare Advantage Star Ratings Explained.
Waiting until December 6. Plan Finder traffic and call center wait times spike in the final week of AEP. Starting your review in October gives you time to fix mistakes before the deadline.

Frequently Asked Questions

When is Medicare Open Enrollment for 2027 coverage?

Medicare Open Enrollment (the Annual Enrollment Period) runs from October 15 to December 7, 2026. Any changes made during this window take effect January 1, 2027.

Do I have to re-enroll in Medicare every year?

No. If you’re satisfied with your current Medicare Advantage or Part D plan and it’s still offered in your area, your coverage continues automatically without action. Reviewing your plan is recommended but not required.

What’s the difference between Open Enrollment and the Medicare Advantage Open Enrollment Period?

The Annual Enrollment Period (Oct 15 – Dec 7) is open to anyone with Medicare and allows the widest range of changes. The Medicare Advantage Open Enrollment Period (Jan 1 – Mar 31) is only for people already enrolled in a Medicare Advantage plan and allows one additional switch or a return to Original Medicare.

Can I switch from Medicare Advantage back to Original Medicare during AEP?

Yes. During the Annual Enrollment Period you can switch from a Medicare Advantage plan back to Original Medicare, and add a standalone Part D drug plan if you need prescription coverage.

What happens if I miss the December 7 deadline?

If you miss AEP, you generally have to wait for the next Medicare Advantage Open Enrollment Period (Jan 1 – Mar 31) if you’re in Medicare Advantage, or a Special Enrollment Period if you qualify for one. Missing enrollment windows can also trigger late enrollment penalties for Part B or Part D.

More in This Medicare Open Enrollment Guide

Not sure your current plan is still your best option?

Compare Medicare Advantage, Part D, and Medigap plans available in your ZIP code before the December 7 deadline.

SeniorAffair.com may earn a commission from partner links above.

This does not affect our editorial coverage. We are not connected with or endorsed by the U.S. government or the federal Medicare program.

Information on this page is general in nature and not a substitute for personalized advice from Medicare.gov, 1-800-MEDICARE, or a licensed insurance agent.

Medicare Open Enrollment Checklist: 10 Questions to Ask

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August 8, 2026

Medicare Open Enrollment Checklist: 10 Questions to Ask

A practical 10-question checklist to review before December 7 so you don’t overpay or lose coverage you need in the new plan year.

By the SeniorAffair.com Medicare Team · Reviewed for accuracy against CMS.gov and Medicare.gov

You don’t need hours to do a thorough Medicare Open Enrollment review—you need the right ten questions. Work through this list before December 7, 2026, and you’ll catch the vast majority of changes that actually affect your costs and coverage next year.

Article Contents

1. What changed in my plan’s Annual Notice of Change (ANOC) letter?

Your plan is required to mail this by September 30, and it lists exactly what’s different for next year—premium, deductible, copay changes, and any network or formulary updates. If you can’t find it, call your plan directly or check your plan’s member portal.

2. Are all my doctors and specialists still in-network?

Don’t rely on last year’s card. Networks reset every January 1. Call each provider’s office directly, or check the plan’s current directory, since plan-published directories aren’t always accurate in real time.

3. Are all my medications still covered, and at what tier?

A drug can stay “covered” while moving to a more expensive tier, dramatically changing your copay. Run your exact medication list, dosages included, through Medicare.gov’s Plan Finder. See Medicare Part D Open Enrollment: Comparing Drug Plans for a full breakdown of how tiers work.

4. What is my plan’s star rating this year?

Ratings are recalculated annually and can shift. A plan that was 4 stars last year might be 3 this year, or vice versa. See Medicare Advantage Star Ratings Explained for how to read the rating and where to find it.

5. What is my total estimated annual cost, not just my premium?

Add premium, expected deductible spending, and expected copay/coinsurance based on realistic usage. A $0-premium plan can cost more overall than a plan with a modest monthly premium once actual usage is factored in. See Medicare Costs in 2027: Premiums, Deductibles, and Limits for a full cost breakdown by Medicare part.

Working through this checklist? Pull up plans in your ZIP code now so you can compare as you go.

6. Would I be better off switching between Medicare Advantage and Original Medicare?

This is worth revisiting every year, not just at 65. Health changes, travel patterns, and available local plans all shift the calculation. See Medicare Advantage vs. Original Medicare: How to Decide for the Full Comparison.

7. If I’m considering Medigap, do I still have guaranteed issue rights?

Outside your initial Medigap Open Enrollment window, insurers in most states can medically underwrite a new Medigap application. If you’re weighing a switch, confirm your state’s specific rules before assuming approval is automatic. See Medigap vs. Medicare Advantage: Which Costs Less?.

8. Do I qualify for a Special Enrollment Period instead of waiting for AEP?

If you’ve moved, lost other coverage, or had another qualifying life event this year, you may not need to wait for AEP at all — and you may be well past a SEP deadline you didn’t know existed. See Medicare Special Enrollment Periods: Do You Qualify? for the full list of qualifying events.

9. Am I at risk of a late enrollment penalty I don’t know about?

If you’ve had any gap in Part B or Part D (or creditable equivalent) coverage, check whether a penalty applies or could apply going forward. See Medicare Open Enrollment Deadlines and Penalties for how both penalties are calculated and how to avoid them.

10. Have I submitted my change—or confirmed I’m staying put—before December 7?

Whether you’re switching plans or deliberately staying with your current one, make sure you’ve either submitted your change or consciously decided to do nothing, rather than letting the deadline pass by default. If you are switching, follow the process in How to Switch Medicare Advantage Plans During Open Enrollment.

Ready to finalize your decision? Compare your shortlist side by side before you submit your change.

Finalize My Comparison →

Printable Summary Checklist

Read my ANOC letter for next year’s changes
Confirm my doctors and specialists are still in-network
Confirm my medications are covered, and check their tier
Check this year’s star rating for my plan and any alternatives
Calculate total estimated annual cost, not just premium
Reconsider Medicare Advantage vs. Original Medicare
Check my Medigap guaranteed issue status, if relevant
Check whether a Special Enrollment Period applies to me
Check for any late enrollment penalty risk
Submit my change, or confirm I’m intentionally staying, before December 7

How Long Should This Actually Take?

For most people who are staying reasonably close to their current coverage and just double-checking for changes, this review takes about 20–30 minutes using Medicare.gov’s Plan Finder with your medications and doctors pre-loaded. If you’re seriously considering a structural change—switching from Original Medicare to Medicare Advantage, for example, or vice versa—budget closer to an hour, or set aside time with a licensed agent or your state’s SHIP counselor to walk through the tradeoffs in Medicare Advantage vs. Original Medicare: How to Decide and Medigap vs. Medicare Advantage: Which Costs Less? together.

When to Start

Your ANOC letter arrives by September 30, and AEP itself opens October 15. Starting your review as soon as the ANOC letter arrives — rather than waiting for October 15 — gives you a two-week head start before the Plan Finder tool and 1-800-MEDICARE call lines get busier heading into the final weeks of the window.

What to Do If You’re Reviewing for a Parent or Spouse

Bring their Medicare number, a current medication list with dosages, and their provider list to the review. Because enrollment changes generally require the beneficiary’s own consent (or a documented authorized representative on file), plan to do this checklist together rather than making the decision and presenting it as final. Many family members find it easiest to walk through questions 1–5 together in one sitting, then take a day to think over questions 6–7 before finalizing anything.

Red Flags Worth Double-Checking

A “no change” ANOC letter for a plan that had major issues last year. Absence of a stated change doesn’t always mean nothing shifted—it’s still worth a quick Plan Finder comparison.
A significant premium jump with no clear explanation. This is often tied to regional cost trends, but it’s worth confirming rather than assuming, especially if similar plans in your area didn’t see the same increase.
A drug that quietly moved from a preferred to non-preferred pharmacy network. This changes your copay even if the drug itself stayed on the same formulary tier.
A star rating drop of a full point or more. This can signal a meaningful decline in customer service or care coordination quality, even if costs look similar on paper.

After You’ve Made Your Decision

Once you’ve submitted a change or confirmed you’re intentionally staying with your current plan, keep a simple record: the date you reviewed, what you decided, and why. This takes two minutes and makes next year’s review faster, since you’ll have your own reasoning on hand instead of trying to reconstruct it from memory. If you switched plans, confirm your new member ID card arrives before January 1, and keep your old plan’s information on file in case any claims from December need to be resolved under the old coverage.

A Note on Avoiding Decision Fatigue

With dozens of Medicare Advantage and Part D plans often available in a single county, it’s easy to get overwhelmed and either freeze on a decision or grab the first plan that looks reasonable. Working through this checklist in order—rather than jumping straight to browsing plan options—is designed to narrow the field before you start comparing, so you’re evaluating three or four genuinely relevant plans instead of trying to mentally process dozens of options at once. If you still feel stuck after working through all ten questions, that’s a reasonable point to bring your notes to a licensed agent or your state’s SHIP counselor rather than trying to resolve the last few details alone.

Putting It All Together

This checklist ties directly back to the deeper guides in this series: the full mechanics of the enrollment window in our main Open Enrollment guide, the cost tradeoffs in Medicare Costs in 2027: Premiums, Deductibles, and Limits, and the plan-switching mechanics in How to Switch Medicare Advantage Plans During Open Enrollment. Used together, they cover the entire decision from start to finish—you don’t need to research Medicare from scratch every fall; just work through these ten questions with this year’s numbers.

Set a Reminder for Next Year

Since AEP runs the same seven-week window every fall, it’s worth setting a calendar reminder for late September to check for your ANOC letter, rather than relying on memory or a plan’s marketing mailer to prompt the review. A five-minute habit each September, built around this same checklist, is enough to keep pace with the annual changes that quietly reshape Medicare coverage every January 1.

Frequently Asked Questions

How long does a Medicare Open Enrollment review typically take?

For most people confirming their current plan still fits, the review takes about 20-30 minutes using Medicare.gov’s Plan Finder. Considering a bigger structural change, like switching between Medicare Advantage and Original Medicare, often takes closer to an hour.

What documents do I need before starting my Open Enrollment review?

Your Medicare number, a list of current medications with exact dosages, and a list of the doctors and specialists you see regularly. Your plan’s Annual Notice of Change letter is also useful if you have it.

Do I need to do anything if I’m happy with my current Medicare plan?

Not necessarily, but it’s still worth confirming your doctors and medications are still covered next year, since plan networks and formularies reset every January 1 even if your plan name and premium stay the same.

What’s the single most important thing to check during Open Enrollment?

Confirming your medications are still covered, and at what cost tier, tends to catch the most significant year-over-year cost changes, followed closely by confirming your regular doctors are still in-network.

Can I get free help completing this checklist?

Yes. Every state has a free State Health Insurance Assistance Program (SHIP) that offers unbiased Medicare counseling at no cost, in addition to 1-800-MEDICARE and licensed insura

More in This Medicare Open Enrollment Guide

Not sure your current plan is still your best option?

Compare Medicare Advantage, Part D, and Medigap plans available in your ZIP code before the December 7 deadline.

SeniorAffair.com may earn a commission from partner links above. This does not affect our editorial coverage. We are not connected with or endorsed by the U.S. government or the federal Medicare program.

© 2026 SeniorAffair.com — A 55+ Lifestyle Digital Magazine. Information on this page is general in nature and not a substitute for personalized advice from Medicare.gov, 1-800-MEDICARE, or a licensed insurance agent.

Medigap vs. Medicare Advantage: Which Costs Less?

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August 8, 2026

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Medigap vs. Medicare Advantage: Which Costs Less?

Compare Medigap and Medicare Advantage on premiums, out-of-pocket costs, and flexibility to see which structure fits your budget and health needs.

By the SeniorAffair.com Medicare Team · Reviewed for accuracy against CMS.gov and Medicare.gov

“Which costs less, Medigap or Medicare Advantage?” doesn’t have a single answer—it depends on how much health care you actually use in a given year. The two paths structure costs so differently that comparing premiums alone is misleading. Here’s how to think about it heading into Open Enrollment.

Article Contents

Two Different Cost Philosophies

Medigap (Medicare Supplement Insurance) works alongside Original Medicare. You pay a monthly premium—often the largest single line item in your Medicare budget—and in exchange, most or all of your out-of-pocket costs for doctor visits, hospital stays, and other Medicare-covered services are paid by the Medigap policy. The tradeoff is a higher, predictable monthly cost in exchange for very low costs when you actually need care.

Medicare Advantage flips this structure. Premiums are often low or $0, but you pay copays and coinsurance as you use care, up to an annual out-of-pocket maximum required by CMS. The tradeoff is a lower predictable monthly cost in exchange for variable costs tied to how much care you use.

Side-by-Side Cost Comparison

Cost Factor	Medigap + Original Medicare + Part D	Medicare Advantage
Monthly premium	Higher—Medigap premiums commonly range from roughly $100 to $300+ depending on plan letter, state, and age, plus Part B and Part D premiums	Often $0 to modest, plus the standard Part B premium
Cost when you use care	Very low to none, depending on the Medigap plan letter	Copays and coinsurance apply per visit or service until you hit the annual max
Annual out-of-pocket maximum	Effectively capped near $0 out-of-pocket with a comprehensive Medigap plan	Federally required cap, but typically $4,000–$8,850 depending on the plan
Extra benefits (dental, vision, hearing)	Not included; purchased separately	Frequently bundled in
Underwriting to enroll later	Guaranteed issue only during specific windows; medical underwriting may apply otherwise	No medical underwriting to enroll during Open Enrollment

When Medigap Tends to Cost Less Overall

If you have a chronic condition, see specialists frequently, or have had a hospital stay in recent years, the math often favors Medigap despite the higher premium. A single hospitalization under Medicare Advantage can trigger thousands of dollars in copays before you hit the annual out-of-pocket max, while a comprehensive Medigap plan would cover nearly all of that same stay for close to $0 beyond the monthly premium you’re already paying. For people who use care often, the “expensive” premium turns out to be the cheaper path over a full year.

When Medicare Advantage Tends to Cost Less Overall

If you’re generally healthy, see a doctor only for routine visits, and rarely need specialist or hospital care, Medicare Advantage’s low premium can genuinely be the lower-cost option, since you’re not paying for coverage you rarely use. The risk is that your health needs can change unexpectedly—a fall, a new diagnosis, or an unplanned surgery could suddenly put you into copay territory you weren’t budgeting for that year.

Want real numbers instead of ranges? See Medigap and Medicare Advantage premiums quoted for your ZIP code side by side.

The Underwriting Catch With Medigap

This is the detail that trips up the most people. You have a guaranteed issue right to buy any Medigap policy sold in your state, without medical underwriting, during your Medigap Open Enrollment Period—the six months starting the month you’re both 65+ and enrolled in Part B. Outside that window, in most states, insurers can use medical underwriting to deny you a Medigap policy or charge more based on your health history. This matters most for anyone considering starting with Medicare Advantage and “trying Medigap later” — if your health changes in the meantime, you may not be able to switch to Medigap on favorable terms, or at all, depending on your state’s rules. A few states (including New York and Connecticut) have stronger guaranteed issue protections year-round, so it’s worth checking your specific state’s rules.

Practical takeaway: If you’re near your Initial Enrollment Period and think there’s any chance you’ll want Medigap eventually, it’s generally lower-risk to secure it during your guaranteed issue window rather than planning to add it years later.

Medigap Plan Letters and What They Cover

Medigap policies are standardized into lettered plans (A, B, D, G, K, L, M, N, and others, varying slightly by state), each covering a different combination of Medicare’s deductibles, copays, and coinsurance. Plan G and Plan N are among the most commonly chosen for new enrollees, since Plan C and Plan F are no longer available to people who became newly eligible for Medicare on or after January 1, 2020. Every insurer selling “Plan G,” for example, must cover the exact same benefits—the only difference between insurers is the premium and customer service, which makes comparing Medigap largely a price-and-reputation exercise rather than a benefits comparison.

Part D Still Needed Separately With Medigap

Medigap policies don’t include prescription drug coverage. If you go the Original Medicare + Medigap route, you’ll need to separately enroll in a standalone Part D plan—see Medicare Part D Open Enrollment: Comparing Drug Plans for how to compare those.

If frequent doctor visits are part of your year, a Medigap quote might be worth a look before Open Enrollment closes.

Get Medigap Quotes →

A Simple Framework for Deciding

Estimate your realistic annual usage. Routine visits only, or ongoing specialist care and possible hospitalization?
Price both paths using your actual usage estimate, not just the sticker premium.
Check your state’s Medigap guaranteed issue rules if there’s any chance you’d want to add Medigap later.
Weigh network flexibility. See Medicare Advantage vs. Original Medicare: How to Decide for how much this matters if you travel or split time between states.
Factor in extra benefits like dental and vision if those are a meaningful part of your budget either way.

Switching Between Them During Open Enrollment

You can move from Medicare Advantage to Original Medicare + Medigap, or vice versa, during AEP (Oct 15 – Dec 7). The Medicare Advantage side of that switch is guaranteed—there’s no underwriting to join a Medicare Advantage plan during Open Enrollment. The Medigap side is where the guaranteed issue rules above come into play, so it’s worth confirming your state’s specific protections before assuming the switch will go through without underwriting.

A Closer Look at Two Household Budgets

Household A: Low Care Usage

Consider someone who sees a primary care doctor twice a year, takes one generic maintenance medication, and hasn’t been hospitalized in over a decade. Their realistic annual medical spending under Medicare Advantage might be a few hundred dollars in copays, well under even a moderate Medigap premium paid monthly for a full year. For this household, Medicare Advantage is very likely the lower-cost path, and the bundled dental and vision benefits are a bonus rather than a factor that changes the decision.

Household B: Ongoing Specialist Care

Now consider someone managing a chronic condition with quarterly specialist visits, several prescriptions, and a hospital stay roughly every other year. Under Medicare Advantage, each specialist visit and hospital stay generates a copay or coinsurance charge, and a single significant hospitalization could push them close to the plan’s annual out-of-pocket maximum. Under Medigap, those same services are largely covered after the monthly premium, making their annual costs far more predictable and, in years with a hospitalization, meaningfully lower overall. For this household, the higher Medigap premium functions less like an extra cost and more like the price of predictability.

Don’t Forget Part B Premiums Apply Either Way

Regardless of which path you choose, the standard Part B premium applies to everyone with Medicare — it isn’t something Medigap or Medicare Advantage replaces. Higher-income beneficiaries also pay an Income-Related Monthly Adjustment Amount (IRMAA) on top of the standard Part B and Part D premiums, which applies the same way under either path. See Medicare Costs in 2027: Premiums, Deductibles, and Limits for the current IRMAA thresholds and standard premium amounts.

The Bottom Line on Cost

Neither Medigap nor Medicare Advantage is objectively cheaper—each shifts cost risk in a different direction. Medigap trades a higher guaranteed monthly cost for near-total protection against unpredictable medical bills. Medicare Advantage trades a lower guaranteed monthly cost for exposure to variable copays that depend entirely on how much care you end up needing that year. The right choice comes down to how much uncertainty you’re comfortable carrying, and how your health has actually trended over the past few years—not just how you feel about your health today.

Revisiting the Decision Every Fall

Because Medigap premiums typically rise with age and Medicare Advantage plan benefits reset annually, the decision that made sense five years ago isn’t guaranteed to still be the best fit. Reviewing both paths during Open Enrollment each year — even if you ultimately stay put — is the only way to know for certain that your current coverage is still the most cost-effective option available to you.

Frequently Asked Questions

Is Medigap more expensive than Medicare Advantage?

Medigap has a higher monthly premium than most Medicare Advantage plans, but often results in lower total costs for people who use frequent or high-cost care, since it covers most out-of-pocket costs Medicare doesn’t. Medicare Advantage usually costs less for people who use minimal care.

Can I switch from Medicare Advantage to Medigap anytime?

You can request a Medigap policy anytime, but outside your Medigap Open Enrollment Period or a guaranteed issue situation, insurers in most states can use medical underwriting to deny coverage or charge more based on your health history

Does Medigap include prescription drug coverage?

No. Medigap policies do not include Part D prescription drug coverage. You need to enroll in a separate standalone Part D plan if you have Original Medicare with a Medigap policy.

What is the Medigap Open Enrollment Period?

It’s a one-time six-month window that starts the month you’re both 65 or older and enrolled in Medicare Part B. During this window, you have a guaranteed issue right to buy any Medigap policy sold in your state without medical underwriting.

Which is better for someone with a chronic health condition, Medigap or Medicare Advantage?

Medigap is often more cost-predictable for people with chronic conditions or frequent specialist and hospital use, since it covers most of the out-of-pocket costs Medicare Advantage would charge as copays and coinsurance.

More in This Medicare Open Enrollment Guide

Not sure your current plan is still your best option?

Compare Medicare Advantage, Part D, and Medigap plans available in your ZIP code before the December 7 deadline.

SeniorAffair.com may earn a commission from partner links above. This does not affect our editorial coverage.

We are not connected with or endorsed by the U.S. government or the federal Medicare program.

Information on this page is general in nature and not a substitute for personalized advice from Medicare.gov, 1-800-MEDICARE, or a licensed insurance agent.

Medicare Special Enrollment Periods: Do You Qualify?

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August 8, 2026

Medicare Special Enrollment Periods: Do You Qualify?

A guide to Medicare Special Enrollment Periods (SEPs)—the life events that let you change coverage outside the Annual Enrollment Period.

By the SeniorAffair.com Medicare Team · Reviewed for accuracy against CMS.gov and Medicare.gov

Open Enrollment (Oct 15–Dec 7) isn’t the only time you can change Medicare coverage. If a specific life event happens to you, a Special Enrollment Period (SEP) can open a window to make changes outside the normal fall schedule — sometimes for 60 days, sometimes longer, depending on the trigger.

Article Contents

What Counts as a Qualifying Event

SEPs exist because Medicare recognizes that life doesn’t wait for October. Below are the most common triggers.

Moving

Situation	SEP Window
You move outside your current plan’s service area	Generally starts the month before you move and continues for 2 full months after
You move, and new plan options become available in your new area	Same window as above—you can choose a new Medicare Advantage or Part D plan
You move back to the U.S. after living abroad	2 full months from the month you move back

Losing Other Coverage

Losing employer or union coverage: a SEP typically applies for 2 months after the coverage ends, allowing you to enroll in Part B (if you haven’t already) and Part D without penalty.
Losing Medicaid eligibility: a SEP applies to help you transition to other Medicare coverage.
Your Medicare Advantage or Part D plan leaves Medicare or stops serving your area: CMS grants an SEP so you’re not left without coverage.

Dual Eligibility and Extra Help

If you qualify for both Medicare and Medicaid (dual eligible), or you qualify for Extra Help with Part D costs, you generally get a monthly SEP that allows you to switch Medicare Advantage or Part D plans essentially year-round, not just once. This is one of the more generous SEP categories and reflects the added complexity of coordinating Medicare and Medicaid benefits.

Think you may qualify for a Special Enrollment Period? See which plans are available to you right now.

See Plans at My Address →

5-Star Plan SEP

If a Medicare Advantage or Part D plan rated 5 stars by CMS is available in your area, you can use a special SEP to switch into it once per calendar year, any time outside the normal AEP window. See Medicare Advantage Star Ratings Explained for how star ratings work and where to check them.

Institutional SEP

People who move into, live in, or move out of a skilled nursing facility, long-term care facility, or other qualifying institution get a SEP that allows plan changes essentially any time during that period and for 2 months after moving out.

Other Common SEP Triggers

Event	General Window
Your plan has a contract violation confirmed by CMS	Determined by CMS on a case-by-case basis
You were affected by a federally declared disaster or emergency	An extended window, often several months, determined by CMS for the affected area
You involuntarily lose creditable prescription drug coverage	2 months from the loss of coverage
You enroll in a plan due to a CMS or agent error	Case-by-case correction period through 1-800-MEDICARE

SEP vs. AEP: What’s the Difference?

AEP is open to everyone with Medicare, runs the same seven weeks every year, and allows the widest range of changes. A SEP is triggered only by a specific qualifying event, is usually narrower in what it allows you to change, and the window length depends entirely on which trigger applies. If you don’t have a qualifying event, you’re limited to AEP or the Medicare Advantage Open Enrollment Period (Jan 1 – Mar 31) if you’re already in Medicare Advantage.

Just moved or lost coverage? Compare Medicare Advantage and Part D plans available at your new address.

How to Use a Special Enrollment Period

Confirm you actually qualify. Not every life change creates a SEP—check the specific trigger against Medicare.gov’s list or call 1-800-MEDICARE to confirm.
Act within the window. Most SEPs are time-limited; missing the window generally means waiting for the next AEP.
Gather documentation. Proof of a move, a coverage termination letter, or Medicaid eligibility confirmation can speed up processing.
Compare plans as you would during AEP. The comparison process is identical—see How to Switch Medicare Advantage Plans During Open Enrollment and Medicare Part D Open Enrollment: Comparing Drug Plans.
Enroll online, by phone, or through a licensed agent, noting the SEP reason if asked.

Does a SEP Prevent a Late Enrollment Penalty?

In many cases, yes. Qualifying SEPs, such as losing creditable employer drug coverage, allow you to enroll in Part D without triggering the late enrollment penalty, as long as you act within the SEP window. See Medicare Open Enrollment Deadlines and Penalties for the full penalty rules and how they interact with SEP eligibility.

Common Misconceptions About SEPs

“I can use a SEP anytime I want to switch plans.” No—a SEP requires an actual qualifying event; wanting a different plan isn’t itself a qualifying event.
“A SEP gives me unlimited time to decide.” Most SEP windows are 2–3 months; some are shorter.
“If I miss my SEP window, I’m stuck without coverage.” You may need to wait for the next AEP or Medicare Advantage Open Enrollment Period, but you generally won’t lose existing Original Medicare Part A/B coverage—only your ability to change Advantage or Part D plans on your preferred timeline.

SEPs for Chronic Condition Special Needs Plans

If you’re diagnosed with certain severe or disabling chronic conditions—such as end-stage renal disease, chronic heart failure, or diabetes—you may become eligible to enroll in a Chronic Condition Special Needs Plan (C-SNP) outside of AEP. These plans are designed specifically around managing a particular condition, often with tailored provider networks and care coordination programs, and enrollment eligibility is generally tied directly to your diagnosis rather than a set calendar window.

Working With Your State Health Insurance Assistance Program (SHIP)

Every state has a free, federally funded State Health Insurance Assistance Program that offers unbiased, one-on-one Medicare counseling, including help determining whether a specific life event qualifies you for a SEP. Unlike a licensed insurance agent, SHIP counselors don’t sell plans or earn commissions, which makes them a useful second opinion if you’re unsure whether your situation qualifies or which SEP category applies. You can find your state’s SHIP contact information through Medicare.gov.

Documenting Your SEP Request

When you enroll using a SEP, you’ll typically be asked to select the specific qualifying event from a list, and in some cases provide supporting documentation, such as a termination-of-coverage letter, a new lease or utility bill showing your move date, or a Medicaid approval letter. Keeping these documents on hand before you start the enrollment process can prevent delays, since a plan may place your enrollment on hold while it verifies SEP eligibility if documentation isn’t readily available.

How SEPs Fit Into Your Overall Enrollment Strategy

Even if you don’t currently qualify for a SEP, it’s worth understanding the categories so you recognize a qualifying event when it happens — a job change, a move, or a shift in eligibility for assistance programs can all open a window you’d otherwise miss simply because you didn’t know to look for it. Combined with the standard Annual Enrollment Period and the January–March Medicare Advantage Open Enrollment Period, SEPs round out the full picture of when and how Medicare coverage can change throughout the year.

COBRA and Marketplace Coverage: A Common Point of Confusion

COBRA continuation coverage and ACA Marketplace plans are not considered creditable coverage that delays your need to enroll in Medicare the way active employer coverage can. If you’re turning 65 and currently on COBRA or a Marketplace plan, you generally still need to enroll in Medicare during your Initial Enrollment Period to avoid the Part B and Part D late enrollment penalties — losing COBRA or Marketplace coverage later does not, by itself, typically open a Medicare SEP the way losing active employer coverage does. This is a frequent source of confusion and a costly one, since the penalty clock starts based on your Medicare eligibility date, not your COBRA or Marketplace enrollment status.

A Worked Example: Moving Mid-Year

Say someone enrolled in a Medicare Advantage HMO plan relocates from Arizona to a different county in June. Because the move takes them outside their plan’s service area, their SEP window opens the month before the move and runs for two full months after. During that window, they can select a new Medicare Advantage or Part D plan available in their new county, using the same comparison process as AEP — checking network, formulary, and star rating for the plans now available to them. If they don’t act within that roughly three-month window, they’d need to wait for the next AEP in the fall, potentially leaving them out-of-network in their new location for the rest of the year.

Frequently Asked Questions

What is a Medicare Special Enrollment Period?

A Special Enrollment Period (SEP) is a window outside the standard Annual Enrollment Period that lets you change Medicare Advantage or Part D coverage after a specific qualifying life event, such as moving, losing other coverage, or qualifying for Medicaid.

How long does a Special Enrollment Period last?

It depends on the trigger. Most SEPs last around 2 months from the qualifying event, though some, like the dual-eligible SEP, allow changes essentially monthly, and disaster-related SEPs can last several months.

Can I switch Medicare plans if I move to a new state?

Yes. Moving outside your current plan’s service area triggers a Special Enrollment Period that generally starts the month before your move and continues for 2 full months afterward.

Does losing employer health coverage qualify for a Special Enrollment Period?

Yes. Losing employer or union coverage typically triggers a SEP allowing you to enroll in Part B (if not already enrolled) and Part D within about 2 months, generally without a late enrollment penalty.

Can I switch to a 5-star Medicare plan anytime?

Yes, if a 5-star rated Medicare Advantage or Part D plan is available in your area, you can use the 5-star SEP to switch into it once per calendar year, outside the normal Annual Enrollment Period.

More in This Medicare Open Enrollment Guide

Not sure your current plan is still your best option?

Compare Medicare Advantage, Part D, and Medigap plans available in your ZIP code before the December 7 deadline.

SeniorAffair.com may earn a commission from partner links above. This does not affect our editorial coverage.

We are not connected with or endorsed by the U.S. government or the federal Medicare program.

© 2026 SeniorAffair.com — A 55+ Lifestyle Digital Magazine. Information on this page is general in nature and not a substitute for personalized advice from Medicare.gov, 1-800-MEDICARE, or a licensed insurance agent.

Medicare Part D Open Enrollment: Comparing Drug Plans

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August 8, 2026

Medicare Part D Open Enrollment: Comparing Drug Plans

How to compare Medicare Part D prescription drug plans during Open Enrollment, including the 2026 out-of-pocket cap, formularies, and plan types.

By the SeniorAffair.com Medicare Team · Reviewed for accuracy against CMS.gov and Medicare.gov

Prescription drug costs are one of the biggest reasons to shop around during Medicare Open Enrollment. Part D plans reset their formularies, pharmacy networks, and pricing tiers every January 1, and a plan that covered your medications cheaply this year can look very different next year. Here’s how Part D works and how to compare plans before the December 7, 2026 deadline.

Article Contents

What Part D Covers

Medicare Part D is prescription drug coverage, available either as a standalone Prescription Drug Plan (PDP) alongside Original Medicare or bundled into a Medicare Advantage plan (called MAPD). Each Part D plan maintains its own formulary — a list of covered drugs organized into cost tiers, typically from generic (lowest cost) to specialty (highest cost) medications.

The 2026 Part D Cost Structure

Following changes from the Inflation Reduction Act, the Part D “donut hole” coverage gap that used to exist has been eliminated, replaced with a simpler three-phase structure and a hard annual cap on out-of-pocket spending:

Phase	How It Works
Deductible	You pay 100% of drug costs up to your plan’s deductible (2026 maximum: $615, though many plans set a lower or $0 deductible)
Initial coverage	You pay a copay or coinsurance for each covered drug based on its tier
Catastrophic coverage	Once your total out-of-pocket spending on covered drugs reaches $2,100 (2026), your plan pays 100% of covered drug costs for the rest of the calendar year

CMS is expected to announce final 2027 figures in the fall, closer to the start of AEP — check Medicare Costs in 2027: Premiums, Deductibles, and Limits for the most current confirmed numbers.

New in recent years: The Medicare Prescription Payment Plan (sometimes called “smoothing”) lets you spread your out-of-pocket drug costs into monthly installments across the year instead of paying larger amounts upfront at the pharmacy. It’s voluntary, doesn’t reduce your total costs, and can be requested through your plan.

Want to see exactly which tier your medications fall into? Compare Part D plans in your area with your prescriptions pre-loaded.

Standalone Part D vs. Medicare Advantage Drug Coverage

	Standalone Part D (PDP)	Medicare Advantage with Drug Coverage (MAPD)
Who it’s for	People with Original Medicare	People enrolled in a Medicare Advantage plan
Combined with medical coverage?	No—separate from Part A/B	Yes—bundled into one plan
Formulary and pharmacy network	Varies by standalone plan	Varies by the Advantage plan
Can I switch drug plans separately from medical coverage?	Yes	No—switching drug coverage typically means switching the whole Advantage plan

For the broader medical coverage decision this connects to, see Medicare Advantage vs. Original Medicare: How to Decide.

How to Compare Part D Plans

List every medication you take, including dosage and frequency—even drugs you take occasionally.
Use Medicare.gov’s Plan Finder and enter each drug exactly as prescribed. The tool will show which tier each drug falls into for every plan in your area.
Check your preferred pharmacy — many plans offer lower copays at “preferred” pharmacies within their network versus standard in-network pharmacies.
Compare total estimated annual cost, not premium alone. A $0-premium plan with a high deductible and high-tier copays can cost more overall than a plan with a modest monthly premium.
Check the plan’s star rating for member satisfaction and pharmacy service quality — see Medicare Advantage Star Ratings Explained.

Understanding Drug Tiers

Typical Tier	What’s Included	Typical Cost
Tier 1	Preferred generic drugs	Lowest copay, often $0–$5
Tier 2	Generic drugs	Low copay
Tier 3	Preferred brand-name drugs	Moderate copay
Tier 4	Non-preferred brand-name drugs	Higher copay or coinsurance
Specialty tier	High-cost specialty medications	Highest coinsurance, subject to the annual out-of-pocket cap

The same drug can sit on a different tier from one plan to the next, which is why entering your exact medications into Plan Finder matters more than comparing plans by premium or general reputation alone.

Prior Authorization, Step Therapy, and Quantity Limits

Some drugs on a plan’s formulary require extra steps before they’re covered at the listed price:

Prior authorization: Your doctor must confirm medical necessity with the plan before it’s covered
Step therapy: You may need to try a lower-cost drug first before the plan covers a more expensive alternative
Quantity limits: The plan may cap how much of a drug is covered per month

These restrictions are listed in the plan’s formulary documentation and are worth checking for any medication you take regularly, since they can delay a prescription refill if you’re not expecting them.

A plan with prior authorization on your drug can slow down refills. See which local plans cover your medications with the fewest restrictions.

Compare Drug Plans →

Extra Help and Low-Income Subsidies

If your income and resources fall below certain thresholds, the Extra Help program (also called the Low-Income Subsidy) can significantly reduce or eliminate your Part D premium, deductible, and copays. You can apply through the Social Security Administration at any time of year—it isn’t limited to Open Enrollment. If you think you might qualify, it’s worth checking regardless of where you are in the enrollment calendar.

Late Enrollment Penalty

If you go 63 or more consecutive days without Part D or other creditable prescription drug coverage after your Initial Enrollment Period, you may owe a permanent late enrollment penalty added to your Part D premium for as long as you have Medicare drug coverage. For the full penalty calculation and how to avoid it, see Medicare Open Enrollment Deadlines and Penalties.

When to Switch Part D Plans

A medication you take moved to a higher tier or was dropped from the formulary
Your premium or deductible increased significantly in the Annual Notice of Change letter
Your preferred pharmacy is no longer in the plan’s preferred network
A new medication was prescribed that isn’t well covered by your current plan
You started taking fewer medications, and a lower-premium plan now makes more sense

Any of these are worth a full comparison during Open Enrollment, since Part D plans can only be changed during AEP (or a qualifying Special Enrollment Period) unless you’re also switching Medicare Advantage plans during the January–March window.

The Medicare Prescription Payment Plan, Explained Further

Introduced as part of recent Part D reforms, the Medicare Prescription Payment Plan allows anyone with Part D coverage to spread their out-of-pocket prescription costs evenly across the calendar year rather than paying larger amounts at the pharmacy counter, especially early in the year before a deductible is met. For example, someone who hits a $500 out-of-pocket cost in February could instead pay it off in smaller monthly installments through the rest of the year. It’s entirely optional, doesn’t change your total drug costs, and doesn’t affect your plan’s formulary or tier structure—it only changes the timing of payments. You can opt in by contacting your plan directly, and you can opt out at any point if it’s no longer useful to you.

How Formularies Get Updated Mid-Year

While a plan generally can’t remove a covered drug from its formulary or move it to a higher tier mid-year without proper notice, formularies aren’t entirely frozen. Plans can add new generic drugs at any time, and in specific circumstances—like a drug being pulled from the market for safety reasons—a formulary change can happen outside the normal annual cycle. If your plan does make a mid-year change that affects a drug you’re taking, you’re entitled to advance written notice, and you can request a formulary exception from your plan or discuss alternative medications with your doctor.

Comparing Mail-Order vs. Retail Pharmacy Costs

Many Part D plans offer lower copays for a 90-day supply through mail-order pharmacy compared to filling the same prescription monthly at a retail pharmacy. If you take a stable, long-term medication, checking your plan’s mail-order pricing during your Open Enrollment comparison can meaningfully lower your annual drug spending without changing plans at all. Not every drug is eligible for mail order, particularly certain controlled substances, so it’s worth confirming eligibility for your specific medications.

A Simple Part D Review Checklist

Pull an updated list of every medication, dosage, and frequency
Read your plan’s Annual Notice of Change letter for formulary and pricing changes
Run your medication list through Medicare.gov’s Plan Finder
Compare at least two to three plans on total estimated annual cost
Check whether your preferred pharmacy is in each plan’s preferred network
Look up each plan’s star rating
Ask about mail-order pricing for any long-term maintenance medications
Submit any change before December 7

Why This Review Matters More for Part D Than Almost Anything Else

Of all the moving pieces in a Medicare plan, drug formularies change the most from year to year, because drug pricing itself shifts constantly and insurers renegotiate manufacturer rebates annually. A plan that was the cheapest option for your medications this year can easily become one of the more expensive options next year purely because of formulary tier reshuffling—with no change in your health or your prescriptions at all. That’s precisely why a fresh Plan Finder search every fall, rather than relying on memory of what worked last year, is worth the twenty minutes it takes.

Frequently Asked Questions

What is the Medicare Part D out-of-pocket cap for 2026?

The 2026 Part D out-of-pocket cap is $2,100. Once your out-of-pocket spending on covered drugs reaches that amount in a calendar year, your plan pays 100% of covered drug costs for the rest of the year.

Can I have Part D coverage without Medicare Advantage?

Yes. You can enroll in a standalone Part D Prescription Drug Plan (PDP) alongside Original Medicare. If you have Medicare Advantage, drug coverage is typically bundled into the plan (MAPD) rather than purchased separately.

Is the Medicare donut hole still a thing?

No. The Part D coverage gap, commonly called the donut hole, was eliminated starting in 2025 as part of Inflation Reduction Act changes. Part D now has a simpler three-phase structure: deductible, initial coverage, and catastrophic coverage with a hard annual out-of-pocket cap.

What happens if my drug isn’t on my plan’s formulary?

If a medication isn’t covered, you can ask your plan for a formulary exception, switch to an alternative drug your doctor approves, or compare other Part D plans during Open Enrollment that do cover it.

Can I switch Part D plans every year?

Yes. You can switch standalone Part D plans or switch Medicare Advantage plans with different drug coverage during the Annual Enrollment Period each fall (Oct 15 – Dec 7) or during a qualifying Special Enrollment Period.

More in This Medicare Open Enrollment Guide

Not sure your current plan is still your best option?

Compare Medicare Advantage, Part D, and Medigap plans available in your ZIP code before the December 7 deadline.

SeniorAffair.com may earn a commission from partner links above. This does not affect our editorial coverage.

We are not connected with or endorsed by the U.S. government or the federal Medicare program.

Information on this page is general in nature and not a substitute for personalized advice from Medicare.gov, 1-800-MEDICARE, or a licensed insurance agent.

Medicare Costs in 2027: Premiums, Deductibles, and Limits

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August 8, 2026

Medicare Costs in 2027: Premiums, Deductibles, and Limits

A breakdown of Medicare Part A, Part B, Part D, Medigap, and Medicare Advantage costs—what’s confirmed for 2026 and what to watch for in 2027.

By the SeniorAffair.com Medicare Team · Reviewed for accuracy against CMS.gov and Medicare.gov

Medicare costs are made up of several separate pieces—Part A, Part B, Part D, and, depending on your path, either Medigap or Medicare Advantage cost-sharing. Here’s a breakdown of confirmed 2026 figures, what typically changes each fall, and what to watch for as CMS finalizes 2027 numbers ahead of Open Enrollment.

A note on timing: CMS typically announces final Part A, Part B, and Part D figures for the coming plan year in the fall, close to the start of the Annual Enrollment Period. The figures below reflect confirmed 2026 amounts; check back here or Medicare.gov directly once CMS finalizes 2027 numbers.

Part A Costs

Cost	2026 Amount
Monthly premium	$0 for most people who paid Medicare taxes for at least 10 years; otherwise, up to several hundred dollars per month
Inpatient hospital deductible (per benefit period)	Set annually by CMS; generally increases modestly each year
Skilled nursing facility coinsurance (days 21–100)	A set daily coinsurance amount, adjusted annually

Most beneficiaries qualify for premium-free Part A based on their own or a spouse’s work history, making Part B and Part D premiums the more consistently relevant costs to plan around.

Part B Costs

Cost	2026 Amount
Standard monthly premium	$202.90, up from $185.00 in 2025
Annual deductible	Set annually by CMS
Coinsurance after deductible	Generally 20% of the Medicare-approved amount for most services

Higher-income beneficiaries pay more than the standard Part B and Part D premiums. IRMAA is based on your modified adjusted gross income from two years prior (your 2025 tax return determines your 2027 IRMAA bracket) and is recalculated annually as income thresholds adjust. If your income has dropped since that reference year—due to retirement, a life-changing event, or other circumstances—you can request a reconsideration with Social Security using Form SSA-44 rather than paying the higher amount automatically.

Curious what you’d actually pay under a specific plan? Get a personalized total cost estimate for your ZIP code.

Part D Costs

Cost	2026 Amount
Maximum annual deductible	$615 (many plans set a lower or $0 deductible)
Out-of-pocket cap (catastrophic threshold)	$2,100
Premium	Varies significantly by plan; averages have trended down slightly in recent years as competition among plans increased

See Medicare Part D Open Enrollment: Comparing Drug Plans for how the three-phase Part D cost structure works and how to compare plan-specific pricing.

Medicare Advantage Costs

Cost	Typical 2026 Range
Monthly premium	Often $0, though some plans charge a premium in exchange for richer benefits
Annual out-of-pocket maximum (in-network)	Federally capped, commonly in the $4,000–$8,850 range depending on the plan
Copays and coinsurance	Vary by plan and service — primary care, specialist, hospital, and drug copays are all set individually by the plan

You still pay the standard Part B premium (or your IRMAA-adjusted amount) even while enrolled in Medicare Advantage, since Part C is built on top of your existing Part A and B eligibility.

Medigap Costs

Cost	Typical Range
Monthly premium	Commonly $100–$300+ depending on plan letter, state, insurer, and your age at enrollment
Out-of-pocket costs for covered services	Minimal to none with a comprehensive plan letter like Plan G

Medigap pricing methods vary by state—some insurers use “attained-age” pricing (premiums increase as you get older), others use “issue-age” pricing (premiums are based on your age when you first bought the policy and don’t increase due to age alone), and others use “community-rated” pricing (everyone in an area pays the same premium regardless of age). This distinction can meaningfully affect your long-term costs, so it’s worth asking an insurer directly which pricing method applies. See Medigap vs. Medicare Advantage: Which Costs Less? for the full cost tradeoff between Medigap and Medicare Advantage.

What Tends to Change Each Year

The standard Part B premium and deductible—adjusted annually based on program costs
The Part D out-of-pocket cap—indexed to Part D spending growth under the Inflation Reduction Act
IRMAA income thresholds—adjusted for inflation
Individual Medicare Advantage and Part D plan premiums, deductibles, and copays—set independently by each insurer
Medicare Advantage plan availability—insurers can enter or exit specific counties from year to year

Skip the manual math. Compare estimated annual costs across plans automatically.

Estimate My Costs →

Estimating Your Total Annual Cost

The single biggest budgeting mistake is comparing plans by premium alone. A complete estimate should include:

Monthly premiums (Part B, plus Part D or Medigap, plus any Medicare Advantage premium) × 12
Expected deductible spending based on your typical annual usage
Expected copay or coinsurance spending for routine visits, specialist visits, and any planned procedures
A buffer for unplanned care, capped at the plan’s annual out-of-pocket maximum if you have Medicare Advantage

Medicare.gov’s Plan Finder tool calculates this automatically once you enter your medications and expected usage, which is why it’s worth using directly rather than estimating by hand.

Where to Find the Final 2027 Numbers

CMS typically releases final Part A, Part B, and Part D cost figures for the upcoming plan year in the fall, ahead of the October 15 start of Open Enrollment. Once released, updated numbers are reflected on Medicare.gov and in each plan’s Annual Notice of Change letter, mailed by September 30. Check our main Open Enrollment guide for the latest confirmed figures as they’re announced.

Programs That Can Lower Your Costs

Several assistance programs can reduce Medicare costs for beneficiaries with limited income and resources, and none of them are tied to the Open Enrollment calendar—you can apply any time of year:

Extra Help (Low-Income Subsidy): reduces or eliminates Part D premiums, deductibles, and copays for qualifying beneficiaries. Applied for through the Social Security Administration.
Medicare Savings Programs: state-administered programs that can help pay Part B premiums and, in some cases Part A and B deductibles, copays, and coinsurance for beneficiaries who meet income and asset limits.
Medicaid dual eligibility: beneficiaries who qualify for both Medicare and Medicaid often have most of their out-of-pocket Medicare costs are covered by Medicaid, and you typically gain access to a monthly Special Enrollment Period as well—see Medicare Special Enrollment Periods: Do You Qualify?.

If your income is close to any of these program thresholds, it’s worth checking eligibility even if you don’t think you’ll qualify—the income and asset limits are often higher than people assume, and state Medicare Savings Program limits can differ from the federal Extra Help thresholds.

A Worked Cost Comparison

Consider a hypothetical beneficiary paying the standard 2026 Part B premium of $202.90/month ($2,434.80/year), a $35/month Part D plan ($420/year) with $400 in annual drug copays, and occasional specialist visits. Under Original Medicare alone (no Medigap), unpredictable 20% coinsurance on specialist and outpatient costs could add anywhere from a few hundred to several thousand dollars depending on the year. Adding a Medigap Plan G at roughly $150/month ($1,800/year) would push total fixed costs higher but cap nearly all of that coinsurance exposure. A $0-premium Medicare Advantage plan, by contrast, would eliminate the Medigap line entirely but introduce per-visit copays and coinsurance up to the plan’s annual out-of-pocket maximum. Running this kind of side-by-side estimate with your own real numbers—rather than a hypothetical—is exactly what Medicare.gov’s Plan Finder tool is built to do.

Costs That Are Easy to Overlook

Out-of-network costs under Medicare Advantage HMO plans, which can mean paying the full cost of a service if you see a provider outside the network without authorization
Specialty drug coinsurance before you reach the Part D catastrophic phase, which can be a meaningful percentage of a high-cost medication’s price
Skilled nursing facility coinsurance for stays beyond 20 days, which applies under both Original Medicare and Medicare Advantage plans, though the exact daily amount can differ
Dental and vision costs under Original Medicare, since routine care in these categories isn’t covered at all without a separate supplemental policy

Building Your Own Annual Cost Estimate

Rather than relying on national averages, the most reliable estimate uses your actual medications, your actual providers, and your realistic usage pattern from the past year or two as a guide. Someone who visited a specialist four times last year should assume something similar next year unless a health change suggests otherwise, and someone who filled the same three prescriptions monthly for years should carry that forward too. Once you’ve compared that realistic estimate across two or three plans using the Open Enrollment checklist, you’ll have a far more accurate picture than any generic “average Medicare beneficiary spends $X” statistic could give you.

Bottom Line

Medicare’s cost structure has several moving parts, but the core levers are the same every year: your Part B premium (and possible IRMAA surcharge), your choice between Medigap-covered predictability and Medicare Advantage-style variable cost-sharing and your Part D drug plan’s specific formulary and deductible. Reviewing all three together during Open Enrollment, rather than in isolation, is what actually catches the overpayment most beneficiaries never notice.

Frequently Asked Questions

What is the standard Medicare Part B premium for 2026?

The standard Part B premium for 2026 is $202.90 per month, up from $185.00 in 2025. Higher-income beneficiaries pay more through the Income-Related Monthly Adjustment Amount (IRMAA).

What is the Medicare Part D out-of-pocket cap for 2026?

The 2026 Part D out-of-pocket cap is $2,100. Once your covered drug spending reaches that amount, your plan pays 100% of covered drug costs for the rest of the calendar year.

Do I have to pay a premium for Medicare Part A?

Most people qualify for premium-free Part A based on at least 10 years of Medicare-taxed work history, either their own or a spouse’s. Those who don’t qualify pay a monthly premium that can be several hundred dollars.

What is IRMAA and how is it calculated?

IRMAA (Income-Related Monthly Adjustment Amount) is an additional premium higher-income beneficiaries pay on top of the standard Part B and Part D premiums, based on modified adjusted gross income from two years prior.

When does CMS announce final Medicare costs for the next year?

CMS typically announces final Part A, Part B, and Part D cost figures for the upcoming plan year in the fall, shortly before the October 15 start of the Annual Enrollment Period.

More in This Medicare Open Enrollment Guide

Not sure your current plan is still your best option?

Compare Medicare Advantage, Part D, and Medigap plans available in your ZIP code before the December 7 deadline.

SeniorAffair.com may earn a commission from partner links above. This does not affect our editorial coverage.

We are not connected with or endorsed by the U.S. government or the federal Medicare program.

Information on this page is general in nature and not a substitute for personalized advice from Medicare.gov, 1-800-MEDICARE, or a licensed insurance agent.

Medicare Advantage vs. Original Medicare: How to Decide

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August 8, 2026

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Medicare Advantage vs. Original Medicare: How to Decide

A side-by-side comparison of Medicare Advantage and Original Medicare covering costs, networks, and extra benefits to help you choose during Open Enrollment.

By the SeniorAffair.com Medicare Team · Reviewed for accuracy against CMS.gov and Medicare.gov

Every fall, the biggest decision Medicare beneficiaries face isn’t which specific plan to pick—it’s the more fundamental choice between Medicare Advantage and Original Medicare. Both are legitimate ways to get your Medicare benefits, but they work so differently that the “right” answer depends heavily on your health, budget, and travel habits. This guide breaks down the real tradeoffs so you can decide before the December 7 Open Enrollment deadline.

Article Contents

The Basic Structural Difference

Original Medicare is the traditional government-run program: Part A covers hospital stays, Part B covers doctor visits and outpatient care, and you can add a standalone Part D plan for prescriptions and a Medigap policy to cover the gaps. You can see any doctor or hospital in the country that accepts Medicare—no referrals, no network.

Medicare Advantage (Part C) is an alternative way to get your Part A and Part B benefits through a private insurance company approved by Medicare. Most Medicare Advantage plans bundle in Part D drug coverage and add extra benefits like dental, vision, hearing, and fitness programs—but they usually require you to use an in-network provider (HMO) or pay more to go out-of-network (PPO).

Cost Comparison

Cost Factor	Original Medicare + Medigap + Part D	Medicare Advantage
Monthly premium	Part B premium + Medigap premium (often $100–$300+) + Part D premium	Often $0, plus the standard Part B premium
Out-of-pocket maximum	None on Original Medicare alone; Medigap caps most out-of-pocket costs	Federally required annual out-of-pocket max (varies by plan, often $4,000–$8,850)
Predictability	Very predictable with Medigap; you rarely see a surprise bill	Lower monthly cost, but costs vary more visit-to-visit
Extra benefits (dental, vision, hearing)	Not included; must be purchased separately	Frequently included as supplemental benefits

For a deeper cost walkthrough with current 2026 figures, see Medicare Costs in 2027: Premiums, Deductibles, and Limits.

Wondering which plan type fits your budget best? Compare Medicare Advantage and Medigap costs side by side in your area.

Provider Networks and Referrals

This is the single biggest practical difference. With Original Medicare, you can see any provider nationwide who accepts Medicare, with no referrals for specialists. With Medicare Advantage, you’re generally limited to the plan’s network, and HMO plans typically require a referral from your primary care doctor to see a specialist. If you split time between two states, have a specific specialist you’re loyal to, or travel frequently, network restrictions matter a lot more than the premium difference.

Extra Benefits Medicare Advantage Offers

Routine dental cleanings, x-rays, and sometimes major dental work
Eyewear and routine vision exams
Hearing aids and hearing exams
Gym memberships or fitness program allowances
Over-the-counter allowance cards for approved health items
In some plans, transportation to medical appointments or meal delivery after a hospital stay

Original Medicare doesn’t include any of these. If dental and vision coverage matter to you and you want to stick with Original Medicare, you’d need to purchase separate standalone dental/vision insurance.

Who Original Medicare Tends to Fit Better

People who travel often or split time between two states
People with a chronic condition who see multiple specialists and don’t want referral friction
People who prioritize predictable costs and are willing to pay more monthly for a Medigap policy to avoid it
People with a specific out-of-network specialist or hospital system they don’t want to give up

Who Medicare Advantage Tends to Fit Better

People who are generally healthy and want to minimize monthly premiums
People who want dental, vision, and hearing coverage bundled into one plan
People comfortable using a defined network of local providers
People who want prescription drug coverage bundled in automatically

If you’re leaning toward Medicare Advantage, see which plans in your ZIP code include your doctors and dental/vision benefits.

View Local Plans →

Switching Between Them

You’re not locked in permanently. During Open Enrollment (Oct 15–Dec 7), you can move from Original Medicare to Medicare Advantage or from Medicare Advantage back to Original Medicare. If you’re already in Medicare Advantage and just want to try a different Advantage plan, see the process in How to Switch Medicare Advantage Plans During Open Enrollment. One important note: if you drop a Medigap policy to try Medicare Advantage and later want to switch back, you may face medical underwriting to get Medigap again outside your initial enrollment window—explained in Medigap vs. Medicare Advantage: Which Costs Less?.

How Star Ratings Fit Into This Decision

If you’re leaning toward Medicare Advantage, the plan’s CMS star rating is one of the clearest quality signals available—it reflects member satisfaction, customer service responsiveness, and how well the plan manages chronic conditions. See Medicare Advantage Star Ratings Explained for how to read it before you enroll.

A Practical Way to Decide

List every doctor and specialist you currently see, and check whether they’re in-network for any Medicare Advantage plans you’re considering.
Add up your total annual cost estimate for both paths using the Medicare Advantage vs. Original Medicare calculator on Medicare.gov’s Plan Finder.
Consider how often you travel outside your home state.
Decide how much you value bundled extra benefits versus network flexibility.
If still unsure, a licensed agent can run both scenarios side by side using your actual prescriptions and providers.

Two Real-World Scenarios

Scenario A: The Snowbird

Consider someone who spends winters in Florida and summers in Ohio. A Medicare Advantage HMO plan tied to a single-state network would leave them without in-network coverage for half the year, forcing emergency-only care in their second home. Original Medicare, paired with a Medigap policy, follows them anywhere in the country that accepts Medicare, making it the more practical fit even at a higher monthly premium. Some Medicare Advantage PPO plans do offer broader out-of-network coverage, so it’s worth checking whether a PPO option in your area changes this calculation.

Scenario B: The Budget-Conscious, Generally Healthy Retiree

Someone in good health, on no regular prescriptions, who sees a primary care doctor once a year and wants to minimize monthly costs, is often well served by a $0-premium Medicare Advantage plan with dental and vision bundled in. Their annual out-of-pocket exposure is capped, and since they rarely use care beyond routine visits, the network restriction is a minor inconvenience rather than a real limitation.

Most people fall somewhere between these two extremes, which is exactly why running your own numbers—rather than relying on a friend’s experience or a TV ad—matters so much during Open Enrollment.

Regional Availability Varies Widely

Not every Medicare Advantage plan is available everywhere. Insurers build out their networks county by county, so a plan that looks great in a metro area might not exist—or might have a thin network—in a rural county nearby. Original Medicare, by contrast, is available and identical nationwide, since it’s run directly by the federal government rather than licensed state-by-state by private insurers. If you live in a rural area, it’s worth specifically checking how many Medicare Advantage plans are actually offered in your county before assuming you’ll have the same options as someone in a major city.

What If Your Health Needs Change Mid-Year?

Neither Original Medicare nor Medicare Advantage lets you switch outside of Open Enrollment just because a new diagnosis changed your calculus—with one exception. If you’re diagnosed with certain chronic conditions, some insurers offer Chronic Condition Special Needs Plans (C-SNPs); you may become eligible to join outside AEP. Losing employer coverage, moving, or qualifying for Medicaid can also open a Special Enrollment Period regardless of which path you originally chose. See Medicare Special Enrollment Periods: Do You Qualify? for the full list of qualifying events.

Questions Worth Asking Before You Commit

“Is my primary care doctor and every specialist I see in-network for this specific plan?” Ask the provider’s office directly, since plan directories aren’t always current.
“What is the plan’s maximum out-of-pocket limit, and does it include drug costs?” Some Medicare Advantage plans cap medical costs but treat Part D spending separately.
“If I need a Medigap policy later, will I have guaranteed issue rights, or will I face medical underwriting?” This matters most for anyone considering trying Medicare Advantage first with the idea of switching back later.
“Does this plan require referrals to see specialists, and how long does prior authorization typically take?” This affects how quickly you can actually get care, not just what it costs.
“What supplemental benefits are included, and are there eligibility restrictions on using them?” Many advertised extras like transportation or OTC allowances have usage limits or specific qualifying criteria buried in the plan’s Evidence of Coverage document.

Bringing this list to a licensed agent or using it while browsing Medicare.gov’s Plan Finder tool turns an abstract decision into a concrete, side-by-side comparison you can actually act on before December 7.

The Bottom Line

There isn’t a universally “better” option between Medicare Advantage and Original Medicare—there’s only a better fit for your specific health, budget, and travel pattern. The mistake most beneficiaries make isn’t picking the wrong path; it’s picking a path once during their Initial Enrollment Period and never revisiting the decision again, even as their health, finances, or the plans available in their area change. Open Enrollment exists precisely so that decision doesn’t have to be permanent.

Frequently Asked Questions

Is Medicare Advantage cheaper than Original Medicare?

Medicare Advantage often has a lower or $0 monthly premium than Original Medicare plus a Medigap policy, but it typically has higher potential out-of-pocket costs when you actually use care, since it relies on copays and coinsurance up to an annual maximum rather than the flatter, more predictable costs Medigap provides.

Can I see any doctor with Medicare Advantage?

Generally no. Most Medicare Advantage plans use a network of doctors and hospitals, and HMO plans usually require referrals to see specialists. Original Medicare lets you see any provider nationwide who accepts Medicare.

Does Medicare Advantage include prescription drug coverage?

Most Medicare Advantage plans bundle in Part D prescription drug coverage automatically (called MAPD plans). Some, particularly certain PPO or private-fee-for-service plans, do not, so it’s worth confirming for any plan you’re considering.

Can I switch from Medicare Advantage back to Original Medicare?

Yes, you can switch back to Original Medicare during the Annual Enrollment Period (Oct 15 – Dec 7) or during the Medicare Advantage Open Enrollment Period (Jan 1 – Mar 31) if you’re already in a Medicare Advantage plan.

Does Original Medicare cover dental and vision?

No. Original Medicare does not cover routine dental, vision, or hearing care. Many Medicare Advantage plans include these as supplemental benefits, or you can purchase standalone dental/vision insurance alongside Original Medicare.

More in This Medicare Open Enrollment Guide

Not sure your current plan is still your best option?

Compare Medicare Advantage, Part D, and Medigap plans available in your ZIP code before the December 7 deadline.

SeniorAffair.com may earn a commission from partner links above. This does not affect our editorial coverage.

We are not connected with or endorsed by the U.S. government or the federal Medicare program.

Information on this page is general in nature and not a substitute for personalized advice from Medicare.gov, 1-800-MEDICARE, or a licensed insurance agent.

Medicare Advantage Star Ratings Explained

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August 8, 2026

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Medicare Advantage Star Ratings Explained

Learn how CMS calculates Medicare Advantage star ratings, why they matter, and how to use them to compare plans during Open Enrollment.

By the SeniorAffair.com Medicare Team · Reviewed for accuracy against CMS.gov and Medicare.gov

Every Medicare Advantage and Part D plan gets a public quality score from CMS, from 1 to 5 stars, updated once a year. It’s one of the fastest ways to gauge a plan’s real-world performance before you commit to it during Open Enrollment — but most people never look at it, and most who do don’t know what it’s actually measuring.

Article Contents

What the Star Rating System Measures

CMS calculates star ratings using dozens of individual measures grouped into broad categories:

Staying healthy: screenings, tests, and vaccines members received
Managing chronic conditions: how well the plan supports members with diabetes, heart disease, and other ongoing conditions
Member experience: survey results on ease of getting care and satisfaction with the plan
Member complaints and plan performance: complaint volume, disenrollment rates, and how quickly the plan resolves appeals
Customer service: call center responsiveness and accuracy

Part D-specific measures also factor in medication safety and accuracy of drug pricing information provided to members. A plan’s overall star rating is a weighted average across all these individual measures.

How to Read the Rating

Stars	What It Signals
5 stars	Excellent performance; rare and highly regarded
4 stars	Above-average performance
3 stars	Average performance
2 stars	Below-average performance; may signal recurring member issues
1 star	Poor performance; CMS may restrict marketing for consistently low-rated plans

Plans rated consistently below 3 stars for three years in a row are flagged by CMS as “low performing,” and CMS may limit how those plans can be marketed to new members.

Where to Find a Plan’s Star Rating

Star ratings are published on Medicare.gov’s Plan Finder tool alongside each plan’s cost estimate—you don’t need a separate lookup. They’re also listed on CMS’s public Medicare Plan Ratings data release each fall, ahead of the start of AEP. When comparing plans while switching, as covered in How to Switch Medicare Advantage Plans During Open Enrollment, the rating appears right next to each plan’s cost and coverage details.

See star ratings alongside cost and network details for every plan available in your ZIP code.

Why Star Ratings Matter Beyond Bragging Rights

1. They correlate with real member experience

Because a large share of the rating comes from actual member surveys and complaint data, not just marketing claims, a consistently 4- or 5-star plan tends to mean fewer customer service headaches, more accurate claims processing, and better-managed chronic care programs.

2. 5-star plans unlock a special enrollment opportunity

If a 5-star Medicare Advantage or Part D plan is available in your area, you can enroll in it during a special year-round enrollment period, once per year, outside the normal AEP window. This is covered in more detail in Medicare Special Enrollment Periods: Do You Qualify?.

3. CMS uses ratings to determine bonus payments to plans

Plans rated 4 stars or higher receive bonus payments from CMS, which can translate into more generous supplemental benefits — part of why higher-rated plans often, though not always, offer richer extras like dental and vision allowances.

What Star Ratings Don’t Tell You

They don’t guarantee your specific doctor is in-network. Rating and network adequacy are measured separately.
They don’t reflect this specific year’s premium or copay changes. Ratings are based on the prior year’s performance data, not next year’s pricing.
They’re an average across the whole plan membership, not personalized to you. A plan can be excellent at managing diabetes care and mediocre at customer service — the overall star rating blends both into one number.
A high rating doesn’t mean the plan is the cheapest option for your specific medications. Cost and quality are separate axes worth comparing independently.

How Ratings Change Year to Year

CMS recalculates ratings annually based on the most recent full year of data, so a plan’s rating can rise or fall from one Open Enrollment to the next. A plan that was 4 stars last year isn’t guaranteed to stay at 4 stars, which is another reason to re-check ratings during your annual review rather than relying on what you remember from a previous year.

Start with the 4-and-5-star plans in your area, then compare their costs and networks in one place.

Filter by Star Rating →

Using Star Ratings Alongside Cost Comparisons

The most effective way to use star ratings is as a filter, not a final answer. Start by identifying plans in your area rated 4 stars or higher, then compare those specific plans on cost, network, and formulary using the process outlined in Medicare Part D Open Enrollment: Comparing Drug Plans and How to Switch Medicare Advantage Plans During Open Enrollment. This narrows your options to plans with a track record of decent service before you spend time on detailed cost comparisons.

A Word of Caution About Marketing Claims

Insurance marketing materials sometimes highlight a strong rating in one specific category (like “highest-rated for member satisfaction in our region”) without disclosing the plan’s overall star rating, which might be lower. Always check the plan’s official overall CMS star rating on Medicare.gov directly rather than relying on a claim printed in a mailer or ad, since marketing materials can selectively highlight favorable statistics.

How Star Ratings Are Calculated, in More Detail

CMS collects data from several sources throughout the year: the Consumer Assessment of Healthcare Providers and Systems (CAHPS) member survey, HEDIS clinical quality measures, the Health Outcomes Survey, and administrative data the plans themselves report, including complaint tracking through the CMS complaints system. Each individual measure is scored on a 1-5 scale, then measures are weighted—with member experience, complaints, and access measures generally weighted more heavily than process measures—and combined into the plan’s overall Part C rating (for medical coverage) and, if applicable, a separate Part D rating for drug coverage. A Medicare Advantage plan that includes drug coverage (MAPD) gets a combined overall rating that factors in both.

Why Some Plans Choose Not to Participate Fully

Not every Medicare Advantage plan qualifies for a full star rating in its first few years of operation, since CMS requires enough historical member data to calculate certain measures reliably. New plans, or plans with a very small membership base in a given county, may show as “not enough data” rather than a numeric rating. This isn’t necessarily a red flag, but it does mean you’re taking on more uncertainty by enrolling in a newer plan compared with one that has several years of published performance data to evaluate.

Comparing Star Ratings Across Plan Types

HMO, PPO, and Special Needs Plans (SNPs) are all rated using the same underlying CMS methodology, which makes ratings a useful apples-to-apples comparison tool even when you’re weighing very different plan structures. That said, a SNP designed for people with specific chronic conditions is evaluated in part on measures tailored to that population, so comparing a SNP’s rating directly against a general-enrollment HMO’s rating should be done with that context in mind rather than treating the number as perfectly interchangeable across plan types.

A Quick Star Rating Reference for Your Open Enrollment Review

Look up the overall star rating for any plan you’re considering on Medicare.gov’s Plan Finder
Favor plans rated 4 stars or higher when the cost difference is small
If a plan you’re interested in is rated 5 stars, remember you can switch into it once per year outside AEP too
Cross-check the rating against your own priorities—if customer service matters most to you, look at that specific sub-measure, not just the overall blended score
Re-check ratings every year, since they’re recalculated annually and can shift

Star Ratings and Your Broader Enrollment Decision

Star ratings work best as one input alongside the cost and network comparisons covered elsewhere in this guide, not as a standalone deciding factor. A 5-star plan that doesn’t include your doctor or doesn’t cover your medications well isn’t the right choice just because of the rating, and a solid 3.5-star plan that nails your specific network and formulary needs can easily be the better real-world fit. Treat the rating as a quality baseline—a way to quickly rule out plans with a track record of member dissatisfaction—then do the detailed cost and coverage comparison outlined in the main Open Enrollment guide on whatever shortlist remains.

Frequently Asked Questions

What is a good Medicare Advantage star rating?

4 or 5 stars is generally considered strong performance. 3 stars is average. Plans consistently rated below 3 stars for multiple years are flagged by CMS as low-performing, and CMS may restrict how they can market to new members.

Where can I check a Medicare plan’s star rating?

Star ratings are shown directly in Medicare.gov’s Plan Finder tool next to each plan’s cost and coverage details and are also published each fall in CMS’s public Medicare Plan Ratings data release.

Can I enroll in a 5-star Medicare plan outside of Open Enrollment?

Yes. If a 5-star Medicare Advantage or Part D plan is available in your area, you can use the 5-star Special Enrollment Period to switch into it once per year, outside the standard Annual Enrollment Period.

Do star ratings reflect next year’s premium?

No. Star ratings are based on the prior full year of plan performance data, not next year’s premium or benefit changes. You still need to separately compare next year’s costs using the plan’s Annual Notice of Change or Medicare.gov’s Plan Finder.

How often do Medicare star ratings change?

CMS recalculates and publishes star ratings annually, typically each fall ahead of Open Enrollment, so a plan’s rating can go up or down from one year to the next based on the most recent performance data.

More in This Medicare Open Enrollment Guide

Not sure your current plan is still your best option?

Compare Medicare Advantage, Part D, and Medigap plans available in your ZIP code before the December 7 deadline.