When to Get a Second Opinion on Your Medicare Plan

Many people choose a Medicare plan once and never look at it again. But Medicare plans change every year, premiums increase, drug formularies shift, and provider networks shrink. Your health needs evolve too. What worked when you first enrolled may not be the best fit today.

A Medicare second opinion can reveal whether you're overpaying for coverage you don't need, missing benefits that could save you money, or enrolled in a plan that no longer fits your situation. This guide explains when you should get your Medicare plan reviewed, what that process involves, and how to find unbiased advice.

Why Get a Second Opinion on Your Medicare Plan?

Medicare isn't "set it and forget it." Several factors make regular plan reviews essential:

Plans Change Every Year

Insurance companies can modify their Medicare plans annually. These changes can significantly affect your costs:

• Premium increases: Your monthly cost may jump, sometimes substantially
• Network changes: Your doctors or hospitals may leave the plan's network
• Formulary updates: Your medications may move to a higher cost tier or be dropped entirely
• Benefit reductions: Extra benefits like dental, vision, or gym memberships may decrease

Your Health Needs Evolve

The plan that made sense five years ago may not fit your current situation. New diagnoses, new medications, or changes in how often you see specialists all affect which plan works best for you.

You May Have Been Steered Wrong Initially

Many people enroll in Medicare with help from insurance agents who earn commissions. While many agents are ethical, their recommendations may favor plans that pay them more rather than plans that are best for you. A second opinion from someone without financial ties to insurance companies can reveal if you were guided toward the wrong choice.

7 Signs You Need a Medicare Plan Review

While everyone should review their coverage annually, certain situations make a Medicare second opinion especially important:

1. Your Premiums Increased Significantly

If your monthly premium jumped more than $20-30 from last year, it's time to comparison shop. You may find comparable coverage for less with a different plan.

2. Your Doctor Left Your Plan's Network

Seeing an out-of-network provider with a Medicare Advantage plan often means paying the full cost yourself. If your doctor is no longer in-network, you need to either find a new doctor or find a new plan.

3. Your Medications Aren't Covered (or Cost More)

Drug formularies change every year. If your medications moved to a higher tier or were dropped from coverage, you could pay hundreds or thousands more annually. A different Part D or Medicare Advantage plan may cover your drugs at lower cost.

4. You're Paying More Out-of-Pocket Than Expected

If you're surprised by copays, coinsurance, or bills that seem higher than they should be, you may not fully understand your coverage, or you may have a plan that doesn't fit your usage patterns.

5. You've Been Diagnosed With a New Condition

A new health condition, especially one requiring regular specialist visits or expensive medications, can completely change which plan is most cost-effective for you.

6. You've Moved to a New State or County

Medicare Advantage and Part D plans are location-specific. When you move, your current plan may not be available in your new area, or different plans may offer better value. This triggers a Special Enrollment Period, so you can switch outside of Annual Enrollment.

7. You Chose Your Plan Quickly Without Comparing Options

If you enrolled during a busy time, chose based on a single recommendation, or just picked something to "get it done," you may not have the best plan for your situation. It's worth a second look.

For more enrollment pitfalls to watch for, see our guide on common Medicare enrollment mistakes.

What Does a Medicare Plan Review Include?

A thorough Medicare plan review examines multiple aspects of your coverage to determine if you have the right plan or if better options exist.

Review of Your Current Coverage

The review starts with understanding what you have now:

• Are you on Original Medicare, Medicare Advantage, or Medigap?
• What Part D plan do you have (if any)?
• What are your current premiums, deductibles, and out-of-pocket costs?
• Do you have any supplemental coverage?

Analysis of Your Doctors and Providers

If you have Medicare Advantage, an advisor will verify:

• Are your primary care doctor and specialists in-network?
• Are your preferred hospitals and facilities covered?
• What would you pay if you needed to see an out-of-network provider?

Prescription Drug Cost Comparison

Using your medication list, a review calculates your total annual drug costs across multiple plans, including:

• Monthly premiums
• Deductibles
• Copays or coinsurance at each pharmacy you use
• Coverage gap (donut hole) costs

Out-of-Pocket Cost Projections

Based on your typical healthcare usage, a review estimates what you'd actually pay under different plan scenarios, including what would happen if you had a major health event.

Identification of Gaps or Unnecessary Costs

A good review identifies:

• Coverage gaps that could leave you exposed to high costs
• Benefits you're paying for but not using
• Duplicate coverage (like having employer coverage plus Medicare coverage you don't need)

Recommendations for Alternatives

If better options exist, a Medicare plan review provides specific recommendations, not just generic advice to "shop around."

Who Can Give You a Second Opinion?

Several types of professionals can review your Medicare coverage. Each has different trade-offs:

Insurance Agents

Insurance agents can review your coverage for free because they're paid commissions when you enroll in a plan. The problem is that commissions vary by plan and insurer. An agent may not recommend the best plan for you if it pays less commission.

SHIP Counselors

The State Health Insurance Assistance Program (SHIP) provides free, unbiased Medicare counseling in every state. SHIP counselors are typically volunteers trained by the government. They don't sell insurance and have no financial incentives.

The downside: SHIP services are often overwhelmed, especially during enrollment periods. You may face long wait times, and counselor expertise varies. Find your local SHIP at shiphelp.org.

Fee-Only Medicare Advisors

Fee-only advisors charge you directly for their services. Because they're paid by you (not insurance companies), they have no conflicts of interest. Their only goal is finding what's best for your situation.

The cost is typically $400-600 for a comprehensive review. For many people, the savings from being in the right plan far exceeds this cost.

Learn more about the difference at our fee-only Medicare advisor page or read about what a Medicare consultant does.

Questions to Ask During a Medicare Plan Review

Whether you're working with an agent, SHIP counselor, or fee-only advisor, come prepared with these questions:

1. Is my current plan still the best fit for my needs? The most fundamental question, but make sure you get a specific answer with reasoning.
2. Are all my doctors still in-network? Verify this every year, as networks change.
3. Are my medications covered at the lowest cost? Ask them to show you the tier for each drug and compare to alternatives.
4. What would I pay out-of-pocket if I had a major health event? Understand your maximum exposure with your current plan and alternatives.
5. Are there better plans available in my area? Don't accept "your plan is fine" without seeing the comparison.
6. What are the trade-offs of switching vs. staying? Every choice has pros and cons. Make sure you understand them.

Best Times to Get a Medicare Second Opinion

While you can seek advice anytime, certain periods are particularly important:

Annual Enrollment Period (October 15 - December 7)

This is the primary window when you can make changes that take effect January 1. Getting a review in September or early October gives you time to compare options and make changes before the deadline.

After Receiving Your Annual Notice of Change

By September 30, Medicare Advantage and Part D plans must send you an Annual Notice of Change (ANOC) detailing all plan changes for the upcoming year. This document should trigger your review.

After a Major Health Diagnosis

A new condition, especially one requiring ongoing treatment, may qualify you for a Special Enrollment Period and definitely warrants a coverage review.

After Moving to a New Area

Moving triggers a Special Enrollment Period. You'll need to review your options since different plans are available in different locations.

Anytime You Feel Uncertain

If you're not confident you have the right coverage, that uncertainty is reason enough to seek a second opinion. Peace of mind is valuable.

For a complete overview of when you can make changes, see our Medicare enrollment periods guide.

How to Do a Basic Self-Review

Before seeking professional help, you can do a basic review yourself:

Step 1: Gather Your Current Plan Documents

Find your plan's Summary of Benefits, Evidence of Coverage, and your Annual Notice of Change (if it's fall). Know your current premiums, deductibles, and out-of-pocket maximum.

Step 2: List Your Doctors and Medications

Write down all providers you see regularly, including specialists, and all medications with dosages. You'll need this information to compare plans.

Step 3: Use Medicare Plan Finder

Go to Medicare.gov/plan-compare. Enter your medications and preferred pharmacy to see estimated costs across available plans.

Step 4: Check If Your Doctors Are In-Network

For any plans that look promising, visit the insurer's website and use their provider directory to verify your doctors are in-network.

Step 5: Compare Total Costs

Add up premiums plus estimated out-of-pocket costs for each plan you're considering. The cheapest premium isn't always the cheapest total cost.

Getting Professional Help

If you've done a basic self-review and still have questions, or if your situation is complex, it's time to seek professional help.

When DIY Isn't Enough

Consider professional help if:

• You take multiple medications, especially expensive ones
• You have chronic conditions requiring regular specialist care
• You're considering switching from Medicare Advantage to Medigap (or vice versa)
• You're coordinating Medicare with other coverage (employer, VA, TRICARE)
• You just want someone to verify you're making the right choice

What to Look for in a Medicare Advisor

• Transparency about compensation: They should clearly explain how they're paid
• Willingness to recommend staying put: If your current plan is best, they should say so
• Access to multiple options: Beware of anyone who only recommends one company's plans
• Focus on your needs: They should ask detailed questions about your situation before making recommendations

Questions to Ask Before Hiring Someone

1. How are you compensated? Do you receive commissions from insurance companies?
2. How many plans/companies will you compare for me?
3. What information do you need from me to do a thorough review?
4. Will you provide a written analysis I can review?

Learn more about our approach at Medicare consultant services.