Millions of Americans face critical healthcare choices this autumn as Medicare’s annual open enrolment period begins. A steep rise in out-of-pocket costs for Medicare Advantage plans adds urgency to selecting the right coverage.
From 15 October to 7 December, over 65 million beneficiaries will have the opportunity to review or change their plans. But many risk missing out on better options due to lack of awareness or the complexity of the system. With a 40% increase in maximum in-network costs over five years, choosing incorrectly could prove costly.
Drug Coverage and Provider Networks Top List of Review Priorities
According to Marcia Mantell, a Medicare consultant and author of Creating Your Medicare Recipe, the first step in making the right decision is to review prescription drug coverage. Beneficiaries need to confirm whether their current or new medications remain on the plan’s formulary. She highlights that pharmacy networks shift regularly, potentially increasing costs if a preferred pharmacy has lost its “in-network” or “preferred” status.
“You don’t want to pay more for your drug plan than you have to,” Mantell told the Decoding Retirement podcast. The difference between a low-premium plan and one with high copays for generics could total hundreds of dollars annually, she noted.
Equally important is the status of healthcare providers. A key concern is whether primary care doctors, specialists and hospitals remain within a plan’s network. Mantell advised individuals to contact providers directly, warning that plan directories are not always up to date.
Even with PPO plans, she added, access to prestigious facilities like the Cleveland Clinic may still be restricted or subject to significantly higher charges. While Medicare Advantage plans may appear convenient, they can limit options for serious care unless the provider explicitly accepts the plan.
Rising Out-Of-Pocket Caps and Hidden Costs Under Scrutiny
The third and fourth steps in Mantell’s review method involve understanding both maximum out-of-pocket costs and the copay structure. In 2025, the maximum in-network out-of-pocket cost for Medicare Advantage plans has reached $9,350, up from $6,700 in 2020, according to Medicare data. For those accessing out-of-network PPO services, this figure may go as high as $14,000.
Mantell warns beneficiaries not to be misled by zero-dollar premium ads, stressing: “It is never zero money.” A plan may carry no monthly premium, but hospital stays, specialist visits and other services often carry significant hidden expenses.
Copays for hospitalisation are also rising. Some plans now require patients to pay for the first five days in hospital—a sharp increase from prior years, where three or four days was the norm. “It used to be sort of standard. You either paid for the first three days, three nights, or the first four. This calendar year, 2025, it went up to five in many of the plans. So will it be six next year? I don’t know. We have to look through the plan document to find out.” Mantell said
More Than the Extras: Evaluate ‘Goodies’ With Caution
Finally, Mantell reminds people to examine the extra benefits many Medicare Advantage plans advertise, such as dental, vision or hearing aid support. While these perks can be attractive, they are not guaranteed from year to year and are subject to change. In some cases, providers may choose not to honour a specific plan’s coverage at all.
The five-step framework provides a structured path for reviewing options, but Mantell emphasises that informed decision-making is personal. Beneficiaries are urged to take time—ideally in early November—to use the official Plan Finder tool at Medicare.gov and compare policies side by side.
