Decision Prep
The Medicare Cost Question to Ask Before You Compare Plans
One question, asked of yourself first, makes every other Medicare cost comparison sharper.
The short answer
The most useful Medicare cost question is one most plan comparisons skip: what did you actually spend on healthcare and prescriptions in the last twelve months, and what do you reasonably expect to spend in the coming year? With that picture, plan comparisons stop being about which premium is lowest in the abstract and start being about which plan structure best fits your actual usage. The premium, deductible, copays, drug tiers, network rules, and out-of-pocket maximum all matter — but only against your actual pattern of care.
Comparing Medicare plans without your own numbers is like comparing car insurance without telling them what you drive. The quotes come out fast and miss the point.
Why this question matters more than it sounds
Plan brochures and comparison tools tend to lead with the monthly premium. It is the number that fits in a column, the number that sorts easily, the number that wins ads. But the premium is only what you pay whether or not you use care. The deductibles, copays, and out-of-pocket maxes — the numbers that fluctuate with usage — are often what determine your actual annual spend.
Two people in the same county, on the same plan, can have very different annual costs. The difference is usage. A healthy year of two doctor visits and a few generic prescriptions costs almost nothing on most plans. A year with surgery, sustained specialist care, brand-name drugs, or a hospital stay can run thousands of dollars in cost share — and the structure of those cost shares varies a lot from plan to plan.
The honest question is not “which plan is cheapest.” It is “which plan is cheapest given how I actually use care.”
What to actually write down
Spend 20 minutes once a year — when the ANOC arrives, or when you are about to enroll — and answer:
Care patterns: Primary care visits in the last 12 months; specialist visits by specialty; hospital stays; outpatient procedures or surgeries; imaging (MRI, CT, ultrasound); emergency room and urgent care visits; physical therapy, occupational therapy, mental health visits; durable medical equipment.
Prescription patterns: Every drug you take regularly, by name and dosage; pharmacy you use (and whether it is preferred under your plan); any drug you expect to start in the next year.
Provider patterns: Doctors you specifically want to keep seeing; hospitals you would want to use if needed; any out-of-area travel where care might be needed.
Income picture: Whether your income is near an IRMAA bracket; whether a life-changing event in the next year might shift income.
You will not use all of this on every plan comparison. You will use most of it once. The work is front-loaded; the payoff lasts the year.
What to do with the picture
For Original Medicare + Medigap + Part D versus Medicare Advantage: Compare the premium total (Part B + Medigap + Part D) on the OM/Medigap side against the MA plan’s premium (often $0). Add in expected cost share on each side using your actual usage. The OM side often costs more in monthly premium and less in cost share; the MA side often does the reverse. Which one wins for you depends on how much care you used and expect to use.
For comparing MA plans against each other: Use Medicare’s Plan Finder at Medicare.gov with your full drug list and preferred pharmacy. The tool will model your specific annual cost across plans.
For comparing Part D plans: Same tool, same approach. The plan with the lowest premium often does not have the lowest annual cost when your specific drugs are entered.
How this applies to you
If you are turning 65 and have no Medicare history. Use your last twelve months of employer-plan claims as the proxy. That history is the best estimate you have for next year.
If you are already on Medicare. Pull your last 12 months of EOBs or your Medicare Summary Notices. Add up actual spend by category. Compare against this year’s plan brochure to see whether the same usage costs more, less, or about the same.
If you are helping someone else. Ask for their MSN or EOB packet from the last six months. The data is in the mail they already received. The work is reading it together.
What this is not
It is not predictive. Healthcare usage can spike in a year you did not expect. The point of the picture is to make better-informed bets, not to predict the future.
It is not a substitute for the Plan Finder or a SHIP counselor. It is the input you bring to those tools. Without it, they can only run averages. With it, they can run your numbers.
It is not a one-time exercise. The picture changes. Update it during the September ANOC review each year. New drug, new specialist, new income — they all change the answer.
Your numbers in the room before the comparison starts. That is the whole move.
The Clearing does not sell insurance, recommend specific plans, or earn commissions. When you are ready to decide, verify the details on Medicare.gov or with a SHIP counselor in your state.
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— Dan, at The Clearing
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