Medicare Open Enrollment: Look Beyond the Premium
October 15 through December 7 is an important opportunity to take a closer look at how your Medicare coverage may work when you actually need care.
Over the last several weeks, our team has spent a significant amount of time advocating for ThriveMore at Home members who needed short-term rehabilitation following hospitalization. Their physicians and care teams believed rehabilitation was appropriate, yet obtaining authorization through their Medicare Advantage coverage became another hurdle at an already difficult time.
Those experiences prompted us to share something we believe every Medicare beneficiary and family member should understand during Medicare Open Enrollment.
Medicare Advantage can be an appropriate and economical choice for many people. Plans may offer lower premiums and additional benefits that Original Medicare does not provide. But Medicare coverage should not be evaluated on premiums and extra benefits alone.
The more important question may be: What will happen when I become sick, have surgery, suffer a fall or stroke, or need rehabilitation, home health care or another significant medical service?
Medicare Advantage and Original Medicare are not the same
A Medicare Advantage plan, also called Medicare Part C, is a Medicare-approved private plan that provides your Medicare Part A and Part B benefits instead of receiving those benefits through Original Medicare. Most Medicare Advantage plans also include prescription drug coverage.
That distinction matters.
With Original Medicare, you can generally use any doctor or hospital in the United States that accepts Medicare. Medicare Advantage plans may require members to use providers within a particular network or service area, and some plans require referrals to see specialists.
Medicare Advantage plans can also require prior authorization before certain services are covered. KFF reports that 99% of Medicare Advantage enrollees are in plans requiring prior authorization for at least some services, with requirements commonly applying to higher-cost services such as inpatient hospital care, skilled nursing facility care and chemotherapy.
What happens when someone needs short-term rehabilitation?
This is particularly important for older adults.
In June 2026, the U.S. Department of Health and Human Services Office of Inspector General released an important investigation into Medicare Advantage prior authorization for skilled nursing facility admissions.
The findings deserve attention.
Looking at June 2024 data from 19 Medicare Advantage organizations:
12% of requests for skilled nursing facility admission were initially denied.
Individual organizations' denial rates ranged from 0.4% to 23%.
Only 18% of the SNF denials were appealed.
But when patients or providers did appeal, an extraordinary 95% of the denials were overturned in favor of the Medicare beneficiary.
That last number is particularly concerning.
The Inspector General said this extremely high overturn rate indicates that some beneficiaries were initially denied medically necessary care and raises questions about the many denials that were never appealed.
An appeal can also mean waiting. LeadingAge's analysis of the OIG findings reports that appeal decisions averaged approximately six days, while 17% took 10 days or longer. For someone sitting in a hospital waiting for rehabilitation, those days can matter.
A particularly important finding involving UnitedHealth
The federal investigation also examined naviHealth, a contractor that processed half of the SNF admission requests studied and is a subsidiary of UnitedHealth Group.
naviHealth denied 14% of the SNF requests it processed. When those denials were appealed, Medicare Advantage organizations subsequently overturned 97% of them.
The Inspector General specifically said these results raise concerns about whether contractors receive appropriate training and oversight from Medicare Advantage organizations.
These federal findings are especially meaningful to me because they mirror something I encounter in real-world care advocacy: a hospitalization is stressful enough without an older adult and family also having to fight an insurance decision to obtain the next level of recommended care.
Rehabilitation isn't the only consideration
Before selecting or renewing Medicare Advantage coverage, I encourage people to look beyond the monthly premium and additional benefits.
Consider:
Your physicians and hospitals.
Medicare Advantage plans may restrict non-emergency care to their provider networks. Original Medicare generally allows you to see any doctor or hospital in the United States that accepts Medicare.
Prescription medications.
Drug plans can use formularies, prior authorization, step therapy and quantity limits. A medication your physician prescribes may therefore require additional approval, or the plan may require another medication to be tried first.
Post-hospital rehabilitation.
Ask whether the plan requires prior authorization for skilled nursing or inpatient rehabilitation and what facilities participate in the network.
Home health and other services.
Prior authorization requirements can extend beyond rehabilitation. When comparing plans, don't evaluate only the care you use today. Think about the care you might need after an unexpected illness, hospitalization or injury.
Open Enrollment is your opportunity to review your decision
Medicare Open Enrollment runs October 15 through December 7, 2026, with changes generally taking effect January 1, 2027. During this period, Medicare beneficiaries can switch Medicare Advantage plans, move from Medicare Advantage to Original Medicare, change prescription drug coverage, or keep their current coverage.
If you move from Medicare Advantage to Original Medicare, Medicare advises that you may need to enroll in a separate Part D prescription drug plan. You may also want Medicare Supplement Insurance, commonly called Medigap, to assist with your share of Original Medicare's out-of-pocket costs. There are limits on when you can obtain Medigap coverage, so don't cancel existing coverage or assume you can purchase a particular Medigap policy without first investigating your eligibility and options.
Medicare recommends reviewing your plan's Annual Notice of Change, checking your prescription medications, confirming that the physicians and facilities you want are in network, and comparing anticipated out-of-pocket costs.
For unbiased Medicare information, visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227).
The Bottom Line
There isn't one Medicare option that is right for every person.
But don't make this decision based solely on a $0 premium, dental coverage, a gym membership or another attractive extra benefit.
Ask the harder questions now, while you are healthy:
Will I be able to see the physicians I want? Are my medications covered? What happens if I need home health? What happens if I'm hospitalized and my physician recommends rehabilitation? Will prior authorization be required? And what are my appeal rights if the answer is no?
Open Enrollment gives Medicare beneficiaries an opportunity to ask those questions before the answers become urgent.
