Medicare & Marketplace: Big Shifts Ahead 

Arthritis Foundation Open Enrollment Episode #141 Transcript – CLEAN – 10/30/25

For Release 11/4/25

Released Nov. 4, 2025

PODCAST OPEN: Thank you for tuning in to the Live Yes! With Arthritis podcast, produced as a public service by the Arthritis Foundation. You may have arthritis, but arthritis doesn’t have you. Here, you’ll get information, insights and tips you can trust — featuring volunteer hosts and guest experts who live with arthritis every day and have experience with the challenges it can bring. Their unique perspectives may help you — wherever you are in your arthritis journey. The Arthritis Foundation is committed to helping you live your best life through our wide-ranging programs, resources and services. Our podcast is made possible in part by the generous financial contributions of people like you. Now, let’s listen in.

Jamie Nicole: Hello, and welcome to the Live Yes! With Arthritis podcast. I'm Jamie Nicole, your guest host for today's episode: Open Enrollment and Arthritis. I am a certified health coach and patient advocate who's been living with multiple chronic illnesses, including rheumatoid arthritis and osteoarthritis, for over 20 years. I'm passionate about helping our community find ways to manage and thrive despite the challenges of chronic illness. Open enrollment for Medicare and Health Insurance Marketplace this year brings some important changes that could impact people living with arthritis. Whether you're enrolling for the first time or making changes to your current plan, we're here to help you understand what's new and what to watch for.

Joining me today are two guests from the Arthritis Foundation who work on these issues. Anna Hyde, vice president of advocacy and access, and Nick Turkas, senior director of health promotion and community connections. So, to get started, could you both tell us a little about yourselves and your expertise in this area?

Anna Hyde: I'll start. My name is Anna Hyde. I lead the advocacy department. And really happy to be talking about open enrollment, which is sometimes a little bit more policy heavy, but that's the other kind of side of what we do. There's advocacy and then there's access. And this really leads into what patients need to know about how to best access their health care. So, really excited for the conversation today.

Nick Turkas: And for more than 25 years, I've been with the Arthritis Foundation, at the local, regional and now at the national level doing patient education and health promotion programs. But I also had the opportunity to spend a year actually working in the insurance industry. So, I do have a little bit of expertise from the inside.

Jamie Nicole: We're going to go ahead and jump right in and talk a little bit about who's impacted. So, the first question is: Who might be affected by the changes affecting Medicare and Marketplace plans this year?

Anna Hyde: There are going to be changes every single year to your health coverage. Most likely, even if you're in an employer-sponsored plan, you'll have changes to your premiums or out-of-pocket costs, because of medical and, you know, inflation and things like that. But for Medicare and Marketplace plans specifically, because those are government-oriented or -run programs, we have more information about what the premiums will be, at least what the baseline premiums will be. So, we will see those premiums going up in both Medicare and Marketplace plans. There are some specific changes in Medicare that might impact some beneficiaries. I know we'll get into that later. And then for Marketplace plans, there are a lot of changes that are going to be rolling out over the next few years. But perhaps for this episode, we'll focus mostly on 2026.

Jamie Nicole: Don't some states have their own Healthcare Insurance Marketplaces? And will these changes affect them, too?

Anna Hyde: The changes are going to affect everyone. So yes, there are 23 states that have their own exchange plans. But many of the plan changes are going to affect all enrollees, no matter where they get their Marketplace coverage. And that does include sort of the cap on out-of-pocket spending and some other eligibility and enrollment changes that we'll also get into as we go here.

Nick Turkas: And we're not spending a lot of time on it today, but for those on Medicaid, I think the biggest thing that many people need to look out for is their eligibility, right? They need to check if they need to re-up for coverage and make sure that they have all of the documents that they need to show that they are eligible. Because now there are some requirements, whether they're work requirements or, in some cases, volunteer requirements, that will count towards your eligibility for coverage.

Jamie Nicole: It's important to make sure that you do that research prior… well, I guess starting right now, so you can be prepared, so you can choose the correct plan for you for this upcoming year. Let's first focus on changes to the Marketplace plans and what else people should know before they enroll. When is open enrollment this year?

Anna Hyde: The One Big, Beautiful Bill Act that was passed over the summer had a lot of changes to Marketplace plans, but those changes roll out over several years. There's been a lot of talk about shortening the open enrollment period. For this year, the open enrollment period for Marketplace plans is November 1st to January 15th. Especially for those plans on the federal Marketplace. Those are the same as what is typically used every year. The shortened time period goes into effect next year. So, I think that's a really, really important point, so that people know they still have that two-and-a-half-month period of time to shop for the right plan for them, and to make the best decision for their health coverage needs. It's next year that we'll really need to focus on that enrollment period being about half as long and needing to make a lot more quickly.

Nick Turkas: And I would urge all of our listeners not to wait to make these decisions, right? As the temperatures change, you know, we always say, when it's time to change the clocks, change your smoke detector battery, it's also time to check your coverage options.

Jamie Nicole: All that information can be overwhelming. And so, if you wait till the last minute, it's just going to add, you know, the extra burden of stress to an already stressful process. If people have a specific state Marketplace, they should look that information up to find out when the enrollment dates are?

Anna Hyde: 100%. If you do get your coverage through the Marketplace, knowing: Is it through the federal exchange or the state? The states will have their own timelines. Usually they're the same, but some go even later than January 15th or have longer special enrollment periods. Where, if you have a change, like you get married, or you move, or you have a baby, or something like that, you can enroll in coverage during the plan year itself. And some even have open sort of window shopping, they call it. In some states, even right now, ahead of that November 1st deadline. So, you can start doing your shopping now.

Nick Turkas: Going to www.healthcare.gov will typically get you those dates, and it will direct you to your state dates. That's sort of the one-stop shop for a lot of these questions about dates and where to start.

Jamie Nicole: That was so helpful. Is that the same for Medicare as well?

Anna Hyde: No, Medicare actually… open enrollment already began. It began October 15th, and it runs until December 7th. So, that's really important, because that will sneak up on you before you know it, that December 7th date. If you are getting your coverage through Medicare, what Nick said earlier about not waiting until the last minute and starting that process now is ever more true than for even the exchange plans.

Jamie Nicole: Absolutely. So now let's talk about subsidies. Marketplace subsidies have been a huge issue lately and led to the government shutdown. Can you explain what the subsidies are — and why they're such a big deal? Who gets them? And how have they changed?

Anna Hyde: When the Affordable Care Act was passed, it included the creation of the health care exchanges, the Marketplace. And what's important about that is: If you get your coverage through your employer, your employer is probably shouldering a lot of the premiums for your plan, right? You're still going to pay a premium most likely every month, but your employer is taking up a lot of that. If you get your coverage through a health exchange, you're shouldering those premiums on your own. So, it's great that the option exists for people to buy coverage on their own without having to have an employer. However, it can still be really unaffordable when you're thinking about how expensive health care costs are.

So, the subsidies were included in the Affordable Care Act to make sure people that were between 100% and 400% of the federal poverty level… So, 400% of the federal poverty level is about $60,000 in annual income for an individual, just to give people some frame of reference. And the subsidies will help lower those premiums and just afford health coverage. In those cases, people can choose mid-range benchmark plans and pay a sliding scale. On the lower income range, a lot of people pay $0 a month for their premiums. It goes all the way up to 8.5% of their total income. But there is that cap on how much of your annual income you'll pay towards your premiums. And that just helps to make sure that you can afford your health care, but also rent and groceries, and all of the other things that people need in order to live. OK, so that's part one.

Part two is that, during the pandemic when, of course, a lot of us needed a lot of extra help — unemployment rose, people either got furloughed, lost jobs, that sort of thing. One of the pandemic relief bills included an enhanced premium tax credit or these enhanced subsidies. So, it lifted that 400% cap, allowing more people to be able to access those subsidies, and it increased the amount of subsidy that even the lower-income population could access. The important thing here is that it actually helped double the amount of Marketplace enrollment. Before that, it was about 11 million people a year were enrolled in Marketplace plans. Now it's closer to 24 million. So, it's a huge number of people who have been able to access health coverage as a result of those subsidies. And it's really been a game changer for many people.

And just to give kind of a fine point to this: Before the enhanced subsidies, only about 36% of enrollees on the federal Marketplace could find a plan with $10 or lower premiums. After those subsidies, enhanced subsidies were introduced; 80% of enrollees are able to find plans that are $10 or less in monthly premiums. That's a huge game changer for people who are juggling all sort of costs and need to have lower premiums.

Nick Turkas: I would say on the macro level as well: When more people have coverage, that's better for the individual, but it's better for the system, right? When more people have access to care and health care systems, and providers have more access to regular payment for regular wellness visits and making sure that their rheumatoid arthritis and their osteoarthritis is managed, that actually saves the system in the long run. So, I think it's really important for us to understand that these subsidies don't just have a benefit to an individual, but they can really help whole communities.

Anna Hyde: Yeah, what Nick said is so important. Because, in order to keep costs down, it's really important to have healthy people with health insurance who aren't using a lot of their care — to kind of offset costs for people who do need a lot of health care. If you have subsidies and other incentives like that, it's much more attractive for the healthier people to have health insurance.

The subsidies also really help people in rural areas. I think that's really important, because costs in rural areas can be a lot higher. There are fewer providers, there are just smaller networks in general. And so, the benchmark plans are usually about 10% higher in rural areas. So, those subsidies are really, really an important lifeline for people who live in those places.

PROMO: As an Arthritis Foundation Advocate, you can help raise awareness about the unique challenges people with arthritis face. Advocates play a vital role in influencing policy changes that promote better health care options and reduce barriers to treatment. Help ensure that everyone with arthritis receives the care and support they need to live their best life. Sign up at arthritis.org/advocate.

Jamie Nicole: What do we know about changes in these premiums going into 2026?

Anna Hyde: Well, states have to file their premium rates ahead of time, several months in advance. So, at this point, we know what each state is planning to raise their premiums by. They filed their rates using current law, which says those enhanced premium tax credits that we talked about are going to expire at the end of this year. That's why this has become such a flash point. If Congress doesn't act to enhance, keep those enhanced tax credits in place, then they will expire. And starting in January, you will not have those subsidies any longer.

Because that is what the current law says, the states are filing rates that are, on average, 18% higher. That's a pretty big increase. Now, it is important to note that those increases aren't all related just to the subsidies. It's also inflation, tariffs on medical products, just basic increased health care use that we're still seeing post-pandemic, where people deferred a lot of health care. Increased prescription drug utilization and other things like that also play a role. But most states are saying that the expiration of those tax credits is the big driver. In some states, those premiums are going to be even higher, in the 20+% range. That could be a really big sea change for people who are right on that bubble of affordability.

Jamie Nicole: You said 18%, and that varies by federal and by state?

Anna Hyde: It does. What you'll see state by state is going to be different depending on all sort of factors that are unique to each state. So that's another place where you can look up different resources — like healthcare.gov, to sort of find out what that average rate might be. But when the actual open enrollment begins, you'll be able to see, plan by plan, what the actual rate in your market is.

Jamie Nicole: And what about deductibles and out-of-pocket expenses?

Anna Hyde: Yeah, deductibles and out-of-pocket expenses: These are some of those sort of costs that do change and tend to rise every year, and some of that is set by law. For 2026, the maximum out-of-pocket limit is going to be $10,600 for an individual and $21,200 for a family. And that actually applies to basically all people, including people on employer-sponsored plans. That includes deductibles, premiums and any other out-of-pocket costs. I think something that's really important to say here, though, and I bet Nick has something to say about this, too, is that you have to keep in mind that those out-of-pocket max only apply to covered benefits.

So, there are particular benefits that health plans have to cover. There are the essential health benefits, for example, which does include prescription drugs. But that doesn't mean that every single prescription drug is on formulary. So, that's why that plan shopping is so important. If you are comparing across plans, you want to make sure you're looking for every single medication that you take, that it's covered on the formulary. And that any sort of procedures, or services, or types of providers that you may need to see through the year are also covered in-network. If it's out of network or if it's not covered on formulary, it does not count towards those maximum out-of-pocket expenses.

Nick Turkas: That's exactly right. And this trips people up all the time, because they just assume all of the health care that they get is covered. And that's really not true. You really need to sort of go back through your calendar, through your year. What appointments did you have? Did you go to physical therapy? Do you have a surgery scheduled? Do you need to buy durable medical equipment? What pharmacies do I use? Those are all of the things that you need to ask yourself and sort of review. And if you don't know if it's covered or not, I mean, you can certainly call your plan. The easiest thing to do is: On the back of your insurance card is a 1-800 number, right? Just call that number and say: What services did I use last year?

Also, our friends in the pharmacy tend to be very helpful. All the medications that you took: What are the costs that you're paying? And ask them to compare what's on formulary for the plan that you have, or a plan that you're thinking about moving to.

Anna Hyde: There's also one more important sort of change in the Marketplace plans. Starting next year, there will be no more $0 plans. We talked earlier about how many people can access $0 monthly premium plans. That will not be true any longer. Every enrollee will have to pay at least $5 a month for their premium.

Jamie Nicole: Would a catastrophic plan be a good choice for me or anyone who's listening? And what are they?

Anna Hyde: Catastrophic health plans are a type of plan that are really designed to provide coverage during emergencies and for preventive care. They have very low monthly premiums, but they have very high deductibles. The deductible is usually the same as that maximum out-of-pocket limit we mentioned. So, that's going to be $10,000 in 2026. Those plans are available to individuals who are under age 30, or for folks who qualify because of a financial hardship, or there's some other exemptions. But typically, they're meant for younger people who have a difficult time affording regular premiums. So, as of September 2025, this is a new change as well. Catastrophic plans are open now to anyone not eligible for subsidies regardless of age. That does open up those catastrophic plans to more people. Those plans do have to cover the 10 essential health benefits, and they do cover three free primary care visits a year, but they are not considered high-deductible health plan. So, you cannot use a health savings account with them.

And as I mentioned, the deductibles typically are very high, so you're probably going to pay full freight for your health costs until you reach that $10,000 mark. I would say, in general, if you are under 30 and you don't have any health conditions that require regular use of health care, it can be an OK option as a stop gap until you're able to afford more comprehensive, robust coverage. But for most people, and certainly people with chronic conditions that do rely on health care, it's not a great option.

Nick Turkas: I would agree 100%. I would maybe even go a step further and say that some coverage is better than no coverage. But you're essentially gambling; because one slip and fall on the sidewalk, a broken arm could cost you tens of thousands of dollars. One ambulance ride could cost you $10,000 in some cases. Especially for people with chronic disease, it's not a good choice. But if you are a quote/unquote, "young and healthy person" for now, it's better than nothing. But get off of that plan as soon as possible. Because medical debt will put you in serious financial hardship. One of the leading causes of homelessness is medical debt. So, you really need to be careful about staying on those plans any longer than necessary.

Jamie Nicole: Absolutely. I went back and looked at my expenses for my insurance and my surgery in 2023 for my arthritis. And what was charged to my insurance was $176,000 for those two surgeries that year. I would assume that if you're on listening to this podcast, that you may have those issues as well. So, making sure that you have coverage is absolutely important. Are there any other changes that we should be aware of for the Marketplace this year?

Anna Hyde: Oh, goodness. There are actually quite a number of other changes. There's three key ones that I'll note for 2026 for people to think about during open enrollment this year. There's no more automatic re-enrollment, that's a huge one. So, if you've already been getting health coverage through the Marketplace and you're used to just being automatically re-enrolled, especially for those subsidies, if you get subsidies, you'll need to actively re-enroll next year. This year, next year and beyond: each year. So, that's one really, really important thing to note. If you do not re-enroll, you'll be charged a monthly premium of $5 or more. And we already talked about: There will no longer be those $0 premiums. And then the third piece is really just that there's going to be more paperwork. Marketplace enrollees are going to need to update their information regarding their income, immigration status and other details every year, or risk losing coverage.

Jamie Nicole: Is there a difference between someone who is enrolling for the first time than there is for someone who is a repeat enrollee?

Anna Hyde: If it were me, I would treat, knowing these rules are going into effect every year as if it's the first time, as if I'm a first-time enrollee. I would shop for coverage across plans as if I were a first-time enrollee. I would look at all of the rules. I would look at everything I'm eligible for in terms of subsidies and other things like that, and know exactly what is required, knowing whether there is or is not automatic renewal of things. How much am I going to be penalized if I don't pay my premiums on time? All of those kinds of things, I think, are really important, no matter what, especially if you're a repeat enrollee: knowing that there are so many changes that are happening right now and will continue to roll out over the next few years. It's really crucial to not take for granted how things have been but think about how things are going to be.

Nick Turkas: And just because your doctor was on the plan last year, it does not mean they'll be on the plan this year. Just because the medication you used was on the plan last year does not mean it's going to be on the plan this year. The pharmacy that you use… Is mail order a good option for you? All of those things, the physical therapist that you use, all of those things that you used… Again, just like Anna said: Double check and act like you are enrolling for the first time and go through all of those providers and services. And at what coverage? Because again, they might be on the list, but what is the copay? What's the coinsurance cost? What is that out-of-pocket max? Because those things can all shift.

And when you're looking at all of those insurance papers, it may look sort of the same. But until you really dig into those details, you won't be sure. But if you are overwhelmed, if you can't do it by yourself, there are lots of people that can help you. So, don't feel like you have to do all this all by yourself. There are lots of resources to help you comb through all of this information and make a good choice.

Jamie Nicole: As someone who deals with multiple doctors, multiple surgeries and multiple visits in labs, one of the most stressful things you can have happen is a doctor that you've been going to and you finally found, that works with you and for you. And they're all of a sudden not on your plan anymore. I know just when my doctor retired, I cried in her office the last time I visited her because she was the one of the only ones who listened to me. I don't normally follow up with my plan at the end of the year as far as the research that you're talking about right now, but I definitely am going forward.

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Jamie Nicole: Let's talk about some Medicare changes. When is open enrollment for Medicare?

Anna Hyde: Medicare is October 15th, so it's already open; start doing your shopping now, and it ends on December 7th. Now, there is some wiggle room at the beginning of the year. There's this kind of special period at the beginning of the year, from January to March, where you can switch between Medicare Advantage plans if you enroll in a Medicare Advantage plan, and you decide, "Hey, you know what? This isn't working for me." Or you can enroll back in original Medicare.

Nick Turkas: It's an option, but no guarantee. And we can talk more about that if we need to.

Jamie Nicole: What are the biggest changes that people on Medicare should know about?

Anna Hyde: Well, just like with the Marketplace plans. You have rising premiums to some extent, and it does depend. Remember, there are different types of Medicare plans. There is Medicare Advantage, and then there's original Medicare, which most people will have a Part D plan. Part D is where you have the prescription drug benefit. A couple of things that I think are important here is that Medicare premiums are going to increase in 2026. Part B, which covers doctor visits and medical equipment, is going to rise about 11.6%. That's from $185 to $206.50. And then Part D, that's that optional prescription drug benefit. The base premium there is expected to go up 6%, from $36.78 to $38.99.

Now, we say base premium, that doesn't mean that that's going to be the premium that every single Medicare beneficiary gets. It just means that's kind of a baseline. And then, depending on where you live, if you're in a higher-cost, lower-cost area, it might go up or down, depending on that. That's why those percentages are really important to think about. That 11% for the base Part B, and then 6% for the Part D.

Jamie Nicole: And you talked about Part D, as far as the drug prescription costs. Last year there was a new out-of-pocket cap for drugs. Is that still the same?

Anna Hyde: It is. And this is really huge. We fought for years to get this cap in place, because, while there was a cap that was put on out-of-pocket costs for employer and Marketplace plans, that never ever existed in Medicare. Something we fought for, for many, many years. Last year, or I guess technically this year, it went into effect: $2,000 cap. Now, that will raise to $2,100 next year as there's always that kind of inflation increase. But $2,100 in Medicare Part D, which is really huge for so many people who rely on especially multiple prescription drugs to manage their care.

Nick Turkas: For people living with inflammatory forms of arthritis — rheumatoid arthritis, psoriatic arthritis — they typically are prescribed high-priced biologic medication, highly effective, high-powered medication. But when you're on commercial insurance, you typically can use a copay card. And most people don't think about the real cost of these medications, because they're paying $5, $10 a month, because of these copay cards. But when you shift to Medicare, you are no longer allowed to use a copay card. And many people used to get this rude awakening: They would have to pay a much significant higher price for those biologic medications. And they typically were unaffordable, or super expensive for people. But now with this $2,000 max, and the fact that it can be spread over the year, it is for many people… provides them access to a medication which really helps keep their disease under control.

Anna Hyde: Oh, that's such an important point. We've had so many calls and patient stories. When you transition onto Medicare, you can no longer use manufacturer copay assistance, which so many of our patients rely on. You know, we were talking about coinsurance earlier. If you have a Marketplace plan with coinsurance, and most of them do have coinsurance for specialty drugs like biologics, you could have a coinsurance of 40% on a biologic medication that's $4,000 a month. I mean, think about what that adds up to every year. Most people need to use some sort of copay assistance to help manage those costs. Then you go to Medicare, and you're not allowed to anymore. It's illegal. It's considered a kickback. And so, what protection is there for those people with Part D plans? That's why we fought so hard for that law that went into effect.

Another thing that Nick mentioned that's really important is that ability to smooth. We call it smoothing those costs over the plan years, so you're not paying it all up front. Because it could be that, you know… Say there's a $2,100 cap, right? But your drug basically costs that much. You might be paying all of that in the first one or two months. And we know a lot of people on Medicare are on fixed incomes, and they can't afford that. And so this program allows you to spread those costs over the plan year. Here's the kicker: You have to opt into it. You are not automatically enrolled in it. You have to opt into it.

And this is the first year of the program. And the early data suggests that people aren't opting into it. And we don't know if it's because patients don't know about this option, or they do, and they don't think it would benefit them. But for whatever reason, the numbers aren't as high as we anticipated they would be. There are plenty of tools, including on our Prescription for Access platform on our website, that can kind of help guide you through: Would you be a patient for whom this would be a really helpful program…

Nick Turkas: We never know what the real cost of the medication is when the doctor gives us that prescription, right? It's really a mystery until we walk up to that pharmacy counter, and the pharmacist says, “This is what you owe.” If that cost is higher than you can afford at the moment, most people walk away. They never tell their doctor. They just don't take the medication, and the disease just gets worse. And this is the worst case scenario.

The best thing that you can do is tell somebody, tell your doctor, tell the pharmacist, tell the Arthritis Foundation. Tell an advocate in your community that you are having trouble affording your medication because the system isn't perfect. But there are lots of places where you can get help and get some additional coverage options. Whether it's through the smoothing, whether it's through a charity assistance, whether it's through Social Security, extra help. But if you silently walk away from the register and don't speak up, no one is going to know that you need help.

Anna Hyde: There's also the low income subsidy program at Medicare, which I'm sure a lot of people don't know about, or that they would even be eligible. One other kind of change that's really interesting for 2026 — and Jamie, I feel like at this point we're just pre-empting all of your questions about Medicare… (laughter) So, I'm just going to roll with it, is that there was another big piece of the Inflation Reduction Act, which had to do with Medicare negotiation. This was in the news a lot, so this probably isn't the first time listeners are hearing about it. But it's been a minute. It hasn't been in the news quite as much lately. But each year, starting… actually going into effect, starting in 2026: There will be the first 10 drugs that were selected for negotiation by Medicare. Those negotiated prices will go into effect. And the reason that's so important for our population is because some of them are arthritis drugs.

There are more than 10 that are going through this process, but in 2026, the initial 10, one of them includes Enbrel. And the negotiated price is about half of what the typical list price is for Enbrel. So, when you factor in that, plus the smoothing program, plus that cap, if you are on Enbrel, that could really be a big deal for your out-of-pocket costs. Now, it's not perfect. A 50% discount on a several-thousand-dollars-a-month drug is still out of reach for most people. But given those other kind of program supports that we've talked about, that is something that could benefit patients.

I will say that there's a flip side to that, which is that plans now are having to kind of shoulder more costs when you talk about these caps and these smoothing programs, and how having to kind of make that operational. And so, one thing that we're going to watch really closely for, and that I absolutely encourage beneficiaries to look for, is increased prior authorization, increased rates of step therapy, narrower formularies and things like that. Because the plans are going to try to put in place these kinds of tools to control costs on their end, as they're having to kind of pick up more costs from these Part D design changes.

Nick Turkas: And I would say this is where you have to be especially vigilant if you are thinking about Medicare Advantage, because Medicare Advantage plans by design are designed to sort of… They're managed care, and they have many more steps as far as prior authorization. That means that your doctor has to put in a special note for the drug to be covered, or step therapy. That means you might have to fail one particular drug to be eligible for another drug, typically a preferred drug. So, they typically have some extra steps, some extra hoops, that you need to go through to get coverage. Now, these plans can often seem attractive, because they run a lot of advertisements. They'll sometimes say: We'll give you a gas card, we'll help pay for your groceries, we'll pay for your prescription lenses, right? But those are things that cost hundreds of dollars. But typically they are putting walls up for things that cost thousands of dollars.

So, you need to think about the overall value of coverage that you're getting. And I'm not saying that Medicare Advantage can't be helpful, because they typically are a lower cost upfront, and that is very attractive for many people. But if you were someone that is a high user of health care, you might want to think or consider staying on what we call traditional Medicare, plus a Medigap plan. That's because traditional Medicare covers 80% of basically anything. You can get any service that your health care provider wants. They're going to cover 80% of it. But that other 20% is up to you. But you can use a Medigap plan to help kind of plug that hole. That is sort of the big trade-off you make when you go to Medicare. And you typically, if you go to Medicare Advantage, you jump over to that side: Just like I said earlier, you can switch back, but it's not a guarantee, because it's not a guaranteed issue anymore.

You may have to get a doctor, a wellness check. They may, if you are no longer as healthy as you were, that plan may no longer be available to you, or will be much, much more expensive. So, again, it's an option. It's something that could be useful for some people. But Medicare Advantage and traditional Medicare, Medigap is not the same. The marketing sometimes can be a little aggressive. So, you have to be very, very careful, and protect yourself. And don't make any rash decisions. Plan ahead, but don't feel like, you know, you need to make a decision right there.

Anna Hyde: Buyer beware.

Nick Turkas: Amen.

Anna Hyde: And Medicare is complicated. I have not enrolled in it myself yet. I'm still a few years away from that, but even people who work in this space, like Nick and I do, still we hear people talk about how absolutely complicated it is. But there is assistance. Every state has a state organization that is dedicated to helping people navigate Medicare coverage. These are your SHIP counselors. SHIP, S-H-I-P, it's an acronym, of course, like everything in health care. But there are dedicated people to help walk you through this. They can lead you to brokers who can kind of help you navigate this, too. Again, you have to kind of be careful: Make sure that you're using a broker who's credible, licensed, all those good things. But there is help there.

Nick Turkas: And those programs are available how you need them. There's information on websites, there's information on apps, there's phone numbers that you can call. And those SHIP programs right now, during this open enrollment process at senior centers all across the country, they are hosting lots and lots of Medicare information nights where they have navigators on staff that will come out. And again, these are folks that are not selling you a particular plan. But they will provide, non-commercial, unbiased information to help you make a good choice. They won't make the choice for you, but they'll help you sort of make those steps. And it's especially folks that are new to this process. It's really, really helpful to check out the SHIP program.

Jamie Nicole: Absolutely, Anna and Nick. I just found out through disability: I could possibly qualify for Medicare. So, this is good information for me as well. And I am a little bit overwhelmed. But I'm going to make sure that I start early with researching more information. So, if this is the first time that I'm enrolling for Medicare, are there other things that I should know, or you mentioned a couple of times there's help out there. Who can help me if this is going to be my first-time enrolling?

Nick Turkas: I'd say first and foremost, the Arthritis Foundation has a Helpline, and you can call 1-800-283-7800, and that's our toll-free Helpline number. We have trained staff that speak English and Spanish and have interpreters available in just about every language that we can help with. And they can handle most general questions about insurance, Medicare, Marketplace. But if they don't know the answer, they can refer you to community partners that can provide deeper assistance. Other places to go are those SHIP programs. Every state has it, but again, if you don't know, go to your local senior center. They typically have lots of great programming, and they typically will have navigators coming out on site. They also have them at like public libraries.

It is important to know that you do need to re-enroll in Medicare each and every year. The good news is, if you are a part of that payment smoothing for prescription medication: That does roll over every year, but you do need to check your coverage and re-enroll. And if you need help, call the Arthritis Foundation's Helpline at 1-800-283-7800. They can also refer you to community organizations like your Area Agency on Aging.

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Jamie Nicole: For this episode, we asked our social media followers: What’s your biggest concern about Medicare or Open Enrollment this year? I’ll share some responses and ask our guests to weigh in. So, the response from Sarah Fox is: “I’m continuing to try to figure out what plans are available to me in my area, in my situation. Hopefully, I can take advantage of Medicare counseling from SHIP counselors in my state.”

Nick Turkas: I'll weigh in and say, that's really savvy of you. SHIP counselors are excellent providers of insurance/Medicare advice. And can give you non-sales advice when it comes to what types of plans are best for you and help walk you through your health care needs. You can go to www.shiphelp.org to help find an event or counselor in your area.

Jamie Nicole: Judy Warland says: “The scam phone calls I keep receiving from supposedly Medicare. I don't think Medicare calls people, do they? I get this call once or twice a week.” Can you all weigh in on that?

Nick Turkas: Yes, you're correct that Medicare will not call you, and that is definitely not only annoying, it could even be illegal for those scam calls to be happening. You, as the health care consumer, should be initiating all of your health care decisions. And you should be reaching out to SHIP, or to Medicare.gov, or a broker directly, to help you make those decisions. But, when people approach you, that's typicallya sure sign that you're not going to get great advice or worse.

Anna Hyde: I totally agree. And this goes for Marketplace plans, too. I would definitely go through those. If it's a state exchange plan program website, healthcare.gov website, talk to a navigator or talk to a SHIP counselor about who a credible broker might be, because those a lot of times false advertising or just straight up scams are certainly out there. And if you want to level up your advocacy even more, when you do, if you do see those calls or get messages, report them in. Report them into your state insurance commissioner or the federal government, to CMS, because that's how we're going to kind of tamp down on those bad practices.

Jamie Nicole: Thank you so much, Anna and Nick. This has been a very informative conversation. We wrap up each episode with our top three takeaways from our discussion. What would you say are your top three? We can start with Anna.

Anna Hyde: Well, my top three are that, number one: It is definitely a lot to keep track of when you're thinking about open enrollment. So, write yourself a checklist of all of the ways that you use health coverage, what are your needs, and then use that as you're comparing plans. Number two, use the many resources that are available to you, whether it's through state exchange websites, healthcare.gov, Medicare, the Arthritis Foundation. There are so many organizations and government agencies that are there to help you. And three, don't get too discouraged. It is a lot to contend with, and there are a lot of changes coming down the pike, not just next year, but in the intervening years afterwards. But we're here to help. It's why we do this podcast. And we'll continue to do that to bring the latest and greatest to you.

Jamie Nicole: Thank you so much. Nick?

Nick Turkas: I echo a lot of what Anna has said. One, plan ahead. What coverage will you need in the future? Two, review your needs, go through everything that you've used in the past, all of your health care providers and services. And three, use your voice, ask for help. If you get confused or overwhelmed, there are so many people that are here to help you. And we want you to get the best health care coverage available.

Jamie Nicole: Thank you so much for that closeout. This has been an excellent conversation. Thank you so much for listening to this episode of the Live Yes! With Arthritis podcast: Open Enrollment and Arthritis. And until next time, you be well.

PODCAST CLOSE: Thank you for listening to the Live Yes! With Arthritis podcast, produced as a public service by the Arthritis Foundation. Get show notes and other episode details at arthritis.org/podcast. Review, rate and recommend us wherever you get your podcasts, on Apple, Spotify and other platforms. This podcast and other life-changing Arthritis Foundation programs, resources and services are made possible in part by generous donors like you. Consider making a gift to support our work at arthritis.org/donate. We appreciate you listening. And please join us again