Choosing a Medicare Advantage plan isn’t a one-time decision. Plans change their premiums, benefits, drug coverage, and provider networks every year, and the plan that worked well for a parent two years ago may no longer be the right fit. For families helping an older parent navigate Medicare, knowing how to compare plans, when changes are allowed, and what to do when coverage falls short can make a real difference in both costs and care access.
This is the third article in Senioridy’s Medicare Advantage series. If you’re newer to the topic, our guides on Medicare Advantage vs. Original Medicare and how Medicare Advantage covers senior care services provide helpful background.
Why Plans Need to Be Reviewed Every Year
Medicare Advantage plans are offered by private insurers approved by Medicare, and those companies can revise plan terms each year. The changes can be significant, and they don’t require a person to take any action to take effect. A parent who enrolled three years ago and hasn’t revisited the choice may be paying more, or getting less, than they realize.
Common year-to-year changes include:
- Monthly premiums and the annual out-of-pocket maximum
- Which doctors, specialists, and hospitals are in the plan’s network
- Drug formularies (the list of covered medications) and their cost tiers
- Supplemental benefits such as dental, vision, hearing, or fitness programs
- Service area coverage for HMO and regional PPO plans
In 2026, there are 231 fewer $0-premium plans available compared to 2025, and supplemental benefits were tightened across many plans as insurers adjusted to updated CMS reimbursement rates. Families who haven’t reviewed a parent’s plan recently may find the coverage has quietly shifted. Medicare sends an Annual Notice of Change (ANOC) to enrolled members each fall, typically in September, which outlines any changes for the coming year. That notice is the practical trigger for an annual review — if a parent received one showing premium increases, benefit reductions, or network changes, the Annual Enrollment Period that follows (October 15–December 7) is the window for making a different choice.
How to Compare Medicare Advantage Plans
The right plan depends on the individual: their health needs, preferred providers, medications, and budget. The comparison process works best when those specifics are in hand before opening any plan directory.
Start With What the Current Plan Provides
Before looking at alternatives, it’s worth taking stock of what the current plan offers and how it’s being used:
- Current monthly premium and annual out-of-pocket maximum
- Network type (HMO, PPO, PFFS, or SNP) and whether referrals to specialists are required
- Drug coverage and any medications requiring prior authorization or step therapy
- In-network status of current doctors, specialists, and preferred hospital
- Supplemental benefits being actively used, such as dental, vision, or transportation
This baseline makes it easier to spot where a different plan might improve on the current situation, and where it might create new gaps.
Use the Medicare Plan Finder
Medicare’s free comparison tool at medicare.gov/plan-compare allows side-by-side comparisons of plans available in a specific ZIP code. It shows premiums, deductibles, out-of-pocket maximums, drug costs for a specific medication list, and quality star ratings. Running this comparison with the actual medication list matters, because drug costs can vary substantially between plans for the same prescriptions. The tool also allows filtering by plan type, so families who want to preserve an HMO or PPO structure can narrow the results accordingly.
Verify Provider Networks Directly
A plan’s online provider directory doesn’t always reflect real-time network status. Before enrolling, it’s worth a direct call to key providers — primary care physician, specialists, and preferred hospital — to confirm they are actively accepting patients under that specific plan. Network changes at the provider level can happen during the year, and a call takes far less time to make than sorting out an out-of-network surprise after the fact.
Review the Star Rating
CMS assigns each Medicare Advantage plan a star rating from 1 to 5 stars, based on quality measures including preventive care, chronic disease management, member experience, and customer service. According to CMS performance data, plans rated 4 stars or higher have generally demonstrated stronger overall performance. Ratings are published each fall before the Annual Enrollment Period and are visible in the Medicare Plan Finder.
Consider Special Needs Plans If Applicable
For people with specific chronic conditions, limited incomes, or institutional care needs, Special Needs Plans (SNPs) may offer more targeted coverage than a standard MA plan:
- Chronic Condition SNPs (C-SNPs): Designed for conditions such as diabetes, heart failure, or chronic lung disease, with care coordination built around that diagnosis
- Dual-Eligible SNPs (D-SNPs): For people enrolled in both Medicare and Medicaid, with coordinated benefits and often lower cost-sharing
- Institutional SNPs (I-SNPs): For people living in nursing facilities or needing nursing-level care at home
SNPs generally include care coordination services and lower cost-sharing for condition-related care. Not all plan types are available in every county, so availability depends on location.
When Switching Is Allowed: Medicare Enrollment Windows
Medicare Advantage has defined periods during which enrollment changes are permitted. Outside of these windows, plan changes are generally not available unless a qualifying life event applies.
Annual Enrollment Period (AEP): October 15 – December 7
This is the primary window each year. During AEP, anyone with Medicare can:
- Switch from one Medicare Advantage plan to another
- Return to Original Medicare (and add a Part D drug plan)
- Join, switch, or drop a standalone Part D prescription drug plan
Changes made during AEP take effect January 1. This is the main opportunity each fall to reassess whether a parent’s plan still fits, especially if the plan has changed its terms for the coming year.
Medicare Advantage Open Enrollment Period (OEP): January 1 – March 31
People already enrolled in a Medicare Advantage plan can use this window to switch to a different MA plan or return to Original Medicare. The OEP doesn’t allow switching from Original Medicare into a Medicare Advantage plan. It’s a practical option for someone who made a change during AEP and found it wasn’t the right fit or who is experiencing problems with a new plan early in the year.
Initial Enrollment Period (IEP)
When someone first becomes eligible for Medicare at 65, or through disability, they have a seven-month window centered on their birthday month to enroll and choose a plan. Missing this window without a qualifying reason can result in late enrollment penalties for Part B and Part D that continue indefinitely. For most people turning 65, this is the first opportunity to choose a Medicare Advantage plan.
Special Enrollment Periods (SEPs)
Outside the standard windows, certain life events trigger a Special Enrollment Period. Common qualifying events include:
- Moving to an address outside the plan’s service area
- Losing employer-sponsored health coverage
- Moving into or out of a nursing facility
- Losing Medicaid eligibility or a Low Income Subsidy
- The plan losing its Medicare contract or significantly reducing its service area
SEPs typically open a two-month window from the qualifying event. Families helping a parent relocate for care reasons may find a SEP allows a plan change that wouldn’t otherwise be available mid-year. A SHIP counselor can confirm whether a specific situation qualifies.
What to Do When a Plan Isn’t Working
Even with careful research at enrollment time, a plan may not perform as expected once a parent is actually using it. Prior authorization delays, claim denials, and provider network gaps are among the more common frustrations families run into. Understanding what options are available and in what order to try them can make a real difference in how quickly a problem gets resolved.
Prior Authorization Challenges
Medicare Advantage plans can require prior authorization before approving certain services, procedures, and medications. Starting January 1, 2026, CMS rules require plans to respond to urgent prior authorization requests within 72 hours and standard requests within 7 calendar days. Plans are also now required to provide specific clinical reasons when a request is denied, rather than a general denial.
When a prior authorization is denied, several options are available:
- Ask the treating provider’s office to request a peer-to-peer review, where the provider speaks directly with the plan’s medical reviewer about the clinical need
- Request the written denial with specific reasoning, which the plan is now required to provide under 2026 CMS rules
- File a formal appeal (see below)
- Contact a SHIP counselor for help understanding options and navigating the process
Filing a Coverage Appeal
Medicare Advantage enrollees have the right to appeal coverage denials. The Medicare appeals process has five levels:
- Level 1: Redetermination by the Medicare Advantage plan – the plan reviews its own decision, with a new reviewer
- Level 2: Reconsideration by a Qualified Independent Contractor (QIC), a reviewer independent of the plan
- Level 3: Hearing before an Administrative Law Judge (ALJ)
- Level 4: Review by the Medicare Appeals Council
- Level 5: Judicial review in federal district court, for amounts meeting the required threshold
For urgent care situations, Level 1 expedited decisions are required within 72 hours. Families who have concerns about how an appeal is being handled may want to contact their state Department of Insurance or reach out to a SHIP counselor for support.
Fast Appeals for Hospital or Facility Discharge
If a parent is in a hospital or skilled nursing facility and the plan issues a discharge date the family believes is too soon, a request for immediate review can be submitted to the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) that serves that region. Submitting the request before the stated discharge date may allow the person to remain in the facility without additional cost liability pending the review outcome. Contact information for regional BFCC-QIOs is available at Medicare.gov.
Filing a Complaint
For concerns about how a plan is handling a claim or service request beyond a specific coverage denial, a formal complaint (also called a grievance) can be filed directly with the plan or submitted to Medicare at 1-800-MEDICARE. Persistent regulatory concerns can be directed to the state Department of Insurance, which handles complaints about insurance companies licensed in that state.
If It’s Not an Enrollment Period: What Families Can Do
When a plan isn’t working and no enrollment window is open, the options narrow but don’t disappear. A few situations that may allow a mid-year change:
- A qualifying SEP event, such as a move outside the service area or a change in Medicaid eligibility
- The plan terminates its Medicare contract or leaves the service area, which triggers a special enrollment period automatically
- The person becomes newly eligible for a Dual-Eligible Special Needs Plan based on qualifying for Medicaid
Outside those circumstances, mid-year plan changes generally aren’t available. For families in that situation, the most productive path is usually to work through the plan’s appeals process for specific denials, file a grievance for service or billing concerns, or connect with a SHIP counselor who can help identify whether any special enrollment option applies. It’s also worth noting that the Annual Enrollment Period is only a few months away for most of the year. Documenting problems now makes the fall comparison process more targeted.
Free Help Navigating Medicare
Comparing plans and working through coverage issues can feel like a lot, especially when a parent is dealing with health challenges at the same time. Several free resources exist specifically to help families through both.
State Health Insurance Assistance Program (SHIP)
SHIP provides free, unbiased Medicare counseling in every state through a network of trained counselors. SHIP counselors are not affiliated with insurance companies and do not sell plans. They can help with:
- Comparing Medicare Advantage plans side by side for a specific situation
- Understanding Medicare rights and how plan rules work
- Preparing and filing appeals, and navigating the appeals process
- Identifying eligibility for low-income subsidy programs such as Extra Help for prescription costs
SHIP is often the most practical resource for families who have a specific problem to work through, not just a general question. Counselors are available by phone or in person and can spend as much time as needed on a situation. To find a local SHIP counselor, visit shiphelp.org.
Medicare Plan Finder and Medicare.gov
The Medicare Plan Finder at medicare.gov/plan-compare is the most practical starting point for comparing plans by ZIP code, cost, drug coverage, and star rating. Medicare.gov also covers the appeals and grievance process step by step, and 1-800-MEDICARE (1-800-633-4227) is available 24 hours a day, 7 days a week for enrollment and coverage questions.
How Medicare Advantage Fits Into the Bigger Care Picture
For families managing a parent’s ongoing care needs, Medicare Advantage is one piece of a larger picture. The plan a parent is on affects which in-home services may be covered, which facilities are available for short-term rehabilitation after a hospital stay, and what out-of-pocket costs to plan for across the year.
Our guide on how Medicare Advantage covers senior care services covers what MA plans do and don’t cover for home health, skilled nursing facility stays, and supplemental benefits. For families navigating the transition from a hospital stay back to home, post-hospital in-home care walks through what that transition typically involves and where Medicare coverage applies. For broader care planning and cost questions, Senioridy’s care plan for aging parents and how to pay for in-home care guides are good places to continue. Having a clear picture of what Medicare covers — and where it stops — makes it easier to plan for what else may be needed.
Find In-Home Care Support Near You
If a parent’s Medicare Advantage plan covers some in-home care services, or you’re exploring private-pay options to fill gaps in coverage, Senioridy’s in-home care directory lists providers by location across the country. Navigating Medicare and care arrangements at the same time is a lot to manage, and having both resources in one place can make the search a little more straightforward.
This article is for informational purposes only and does not constitute legal, financial, or medical advice. Medicare Advantage plan details, premiums, benefits, and network coverage are subject to change each plan year. Information about the Medicare Advantage Improvement Act of 2026 (H.R. 8375) reflects proposed legislation that has not been enacted into law. Always confirm current plan details, network coverage, and enrollment deadlines directly with Medicare or your plan. Families navigating Medicare decisions may want to consult a licensed insurance professional for guidance specific to their situation.