What Your Doctor Wishes You Knew About Medicare Coverage
Your doctor’s office sees it all. From surprise copays to coverage denials, here’s what they want every patient to understand during Annual Enrollment.
Start with your Doctors
Doctors and clinics interact with Medicare Advantage plans every single day. They see patterns with the surprise copays, denied services, prior authorization delays, and the patients who unknowingly pick plans that limit their care.
And the truth? Most of these issues could have been avoided with a quick plan review during the Annual Enrollment Period (AEP).
As we head into 2026, here’s what healthcare providers wish every Medicare patient understood before locking in their coverage (KFF, 2025).
Your Plan Can Change Your Access, Even to Your Favorite Doctor
Networks shift every year as carriers renegotiate contracts–and sometimes, providers chose to leave networks due to reimbursement changes. According to national analyses, Medicare Advantage network changes are increasingly common and can significantly impact access (KFF, 2025).
This means:
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- A doctor you’ve seen for years may suddenly become out-of-network
- A specialist you rely on might no longer accept your plan in 2026
- Large medical groups sometimes switch networks mid-year
Coverage Rules Vary Between Plans
Many patients assume Medicare Advantage plans follow one standard set of rules. Not true. Coverage for:
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- MRIs
- Physical Therapy
- Behavioral Health
- Durable Medical Equipment
- Home Health
- Cardiac Care
…Can vary widely between plans, even within the same county (NCOA, 2025).
Most Importantly:
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- Your doctor does not set coverage rules. Your insurance plan does.
So while your provider may recommend a service, the plan may require:
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- Prior authorization
- Step Therapy
- Proof of “Medical Necessity”
- Using Specific Providers or Locations
Drug Formularies Aren’t All the Same
Studies show that:
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- Many beneficiaries see their prescription tiers shift year-to-year
- Some drugs are removed entirely
- Prior authorization requirements are increasing (CMS, 2026).
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- Push a medication into a more expensive tier
- Require prior authorization
- Stop covering a brand-name option
- Increase costs at your preferred pharmacy (NerdWallet, 2025)
If you take medications daily, this review is non-negotiable.
A Quick Review Saves Frustration Later
Doctors consistently report seeing patients face:
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- Unexpected copays
- Denied Claims
- Delayed surgeris or treatments
- Medication switches due to cost
- Surprise out-of-network charges
We Help You Verify What Matters Most
Enrollment Reminder:
The Annual Enrollment Period (AEP) for Medicare Advantage runs from
October 15 to December 7 (NCOA, 2025).
Book your no-cost Medicare plan review: Schedule Your Consult Here!
References:
Centers for Medicare & Medicaid Services (CMS). (2026). 2026 Advantage and Part D Rate Announcement.
Kaiser Family Foundation (KFF). (2025). Medicare Advantage in 2025: Premiums, Out-of-Pocket Limits, Supplemental Benefits, and Prior Authorization
KFF. (2025). Medicare Advantage 2025 Spotlight: A First Look at Premiums and Benefits.
National Council on Aging (NCOA). (2025). What You’ll Pay in Out-of-Pocket Medicare Costs in 2025.
NerdWallet. (2025). Best Medicare Advantage Plans in 2025.
Medicare Disclaimer: We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.
