The Critical Need to Revisit Medicare: Even (Especially) for Rural Seniors, Dual Eligibles, and Long-time Holders

For many beneficiaries, Medicare becomes “set and forget.” But that can be risky. If you're in a rural area, are dually eligible for Medicare and Medicaid, or haven’t updated your coverage in years, the annual Medicare Open Enrollment season is especially vital. Read on to discover why—and how to act wisely.

What Is Medicare Open Enrollment (AEP)?

The Annual Enrollment Period (AEP) runs October 15 through December 7 each year. It’s the window during which all Medicare beneficiaries can:

• Switch Medicare Advantage (Part C) plans or return to Original Medicare

• Enroll in, drop, or switch a Medicare Part D (prescription drug) plan

• Change from one Medicare Advantage plan to another

• Drop a Medicare Advantage plan and return to Original Medicare (with the option to enroll in Part D)

These changes take effect January 1 of the next year. KFF+2Medicare+2

Outside those dates, most people cannot make plan changes unless they qualify for a Special Enrollment Period (SEP) due to life events (moving, losing coverage, etc.). Medicare+2Medicare Interactive+2

Why It’s Especially Important for These Three Groups

1. Rural Seniors

• Limited plan choices: In many rural counties, the number of Medicare Advantage and Part D plans is smaller, making each change or advantage more meaningful.

• Access concerns: Changes to provider networks can have more severe consequences when your nearest specialist or hospital is far away.

• Transportation & cost sensitivity: Premiums, co-pays, and drug coverage shifts can disproportionately affect beneficiaries who are budgeting for travel, fuel, or limited local services.

• Less frequent review: In remote areas, outreach or agent visits may be less frequent, so beneficiaries are more likely to stick with a plan they haven’t revisited in years.

2. Dual Eligibles (Medicare + Medicaid)

“Dual eligibles” refers to people who qualify for both Medicare and Medicaid. Centers for Medicare & Medicaid Services+2Centers for Medicare & Medicaid Services+2 Because they receive coverage from both programs, coordinating benefits is especially important.

New 2025 changes for duals:

• As of January 1, 2025, dual eligibles may change plans monthly (rather than quarterly). Pennsylvania Health Law Project+3Commonwealth Fund+3Centers for Medicare & Medicaid Services+3

• However, these SEPs (Special Enrollment Periods) are limited in what kinds of plan changes are allowed. Medicare Interactive+3Centers for Medicare & Medicaid Services+3UHC+3

• Not all Medicare Advantage or Dual-Eligible Special Needs Plans (D-SNPs) are integrated; only truly integrated plans coordinate both Medicaid and Medicare services. Centers for Medicare & Medicaid Services+4Medicare+4Centers for Medicare & Medicaid Services+4

• Some previously available “look-alike” plans (plans that enroll many duals but don’t provide integration) are being phased out or more tightly regulated. Justice in Aging+2Centers for Medicare & Medicaid Services+2

Thus, dual eligibles have more flexibility, but also more complexity, in choosing plans that align both Medicare and Medicaid benefits.

3. Those Who Haven’t Reviewed Their Coverage in Years

• Plans change yearly: Premiums, deductibles, formularies (drug lists), and networks often shift. What once was a “good” plan may become suboptimal.

• Your health needs change: New medications, diagnoses, specialists, or location shifts can render your current plan a poor fit.

• Risk of being trapped: If you switch from Medicare Advantage to Original Medicare but are past your Medigap (supplement) open enrollment period, insurers may charge higher rates or deny coverage.

• Missed opportunities: You may be eligible for new benefits (e.g. enhanced supplemental benefits, chronic care supports) or new cost protections you haven’t claimed.

Pros and Cons for These Groups

✅ The Benefits (Pros)

Benefit	Why It Matters for These Groups
Better alignment of coverage & cost	You may find a plan that matches your current health needs (e.g. new drugs, specialists) more cost-effectively
Leverage SEP flexibility (for duals)	Monthly SEP gives duals more freedom to adjust midyear
Avoid surprise network exclusions	You can avoid being locked into a plan that excludes your physician or hospital
Rescue from outdated plans	If your plan has deteriorated (e.g., formulary changes, reduced benefits), you can switch
Opportunity to optimize for local access	Particularly in rural areas, you might find, for the first time, a plan with better telehealth, in-network rural providers, or transportation benefits
Protection from being stuck	By acting in open enrollment, you reduce the risk of being forced into a worse plan later

⚠️ The Challenges (Cons) & Things to Guard Against

Challenge	Why It’s Risky & Tips to Manage
Overwhelming complexity	Too many plan variables (network, drugs, benefit rules) can lead to wrong choices. Use trusted tools or help (SHIP, agents)
Switching into worse plan by mistake	Cheaper premium might come with narrower networks or stricter restrictions
Medigap underwriting risk	If you leave Medicare Advantage and try to get a Medigap later, insurers may impose medical underwriting (denials or higher premiums)
SEP limitations for duals	Not all plan types or changes are allowed under SEPs; you can’t join non-D-SNP Medicare Advantage plans using the dual SEP in many cases. Pennsylvania Health Law Project+3Centers for Medicare & Medicaid Services+3Medicare Interactive+3
Missed deadline = waiting a year	If you skip open enrollment (and don’t qualify for SEP), you're generally locked into your plan for the year
Scams & misuse of agents	High risk of fraud or misleading marketing during enrollment season; always verify credentials and avoid pressure tactics

How to Navigate Open Enrollment: Best Practices for These Audiences

1. Begin early (October) — don’t wait until December.

2. Inventorize your doctors, medications, pharmacies, providers — this is your filter basis.

3. Use the Medicare Plan Finder tool (medicare.gov) to compare side-by-side based on your ZIP, meds, and preferences.

4. Check provider networks and drug formularies carefully — even small changes in coverage or drug tiers matter a lot.

5. For dual eligibles, identify truly integrated D-SNPs in your area to coordinate Medicaid + Medicare.

6. Watch SEP rules — if you change under SEP, the plan’s effective date or coverage options may differ.

7. Be cautious of unsolicited phone calls or aggressive agents — Medicare doesn’t initiate calls asking you to re-enroll.

8. Document your decisions — keep records, plan summaries, conversations, and printouts.

9. Get help from SHIP or trusted local advisors, especially in rural areas.

10. Review each year — even if you think your plan is fine, revisit it annually.

Introducing Simple Business Solutions — A Helping Hand

Simple Business Solutions, Inc. is a firm that offers health insurance services, including Medicare options from carriers like Blue Cross Blue Shield, UnitedHealthcare, Humana, and Wellcare. Simple Business Solu

How they may support you:

• Offer personalized plan education so you’re not overwhelmed by options

• Help particularly with dual-eligible coordination (if they represent D-SNPs or integrated plans)

• Assist rural clients by leveraging their network of agent contacts

• Provide ongoing support year to year so you aren’t “stuck” unexpectedly