I have been on the phone with my sister for the last few days. She has some big decisions to make about her Medicare coverage, and it can be a confusing process.

My sister turns 65 in October.  Because she is currently receiving Social Security benefits, she will automatically be enrolled in Medicare Part A and Part B on the first day of her birthday month (October 1st) or the prior month if her birthday falls on the 1st. 

My sister’s concern is her automatic enrollment in Medicare Part B.

Today, she has COBRA medical coverage from her husband’s previous employer. The employer stated that this coverage will remain in effect until January 6, 2026, if she pays her premiums. However, that is somewhat deceiving for two reasons. COBRA coverage is not considered a viable reason to opt out of Part B and generally COBRA benefits end once Medicare begins.

According to Medicare, you can choose to opt out of Part B before it starts, only if you have active employer coverage from you or your spouse’s current job, otherwise, you may face late enrollment penalties. COBRA is considered continuation coverage — not active employment coverage.

Since neither my sister nor her husband are working, COBRA coverage is not considered an acceptable reason for opting out.

In most cases, COBRA coverage ends when you enroll in Medicare Part A or B. It is important to check this with your COBRA provider since they rarely inform you that your coverage has ended and you will keep paying premiums until your COBRA benefits expire, even when you cannot avail yourself of the insurance benefits.

Today, my sister’s COBRA plan covers her monthly biologic injection with a minimal co-pay, and she has already paid her deductible for this year. She is uncertain whether this drug will be covered under any Medicare plan.

The cash price for her biologic drug ranges from $6,785 to $13,570 per injection. She takes monthly injections. Out-of-pocket costs without insurance could run as high as $162,000 per year.

The Medicare Part D (Prescription Drug Plan) may cover her medication because it is self-administered. However, it must be listed on the Part D plan’s formulary (covered drug list).

If her monthly biologic injection is on the list, she may still be subject to co-pays, coinsurance, deductibles, and coverage gap ("donut hole") costs. My sister needs to know those details before signing up for a plan.

I have encouraged her to speak with a licensed insurance agent or a certified Medicare counselor.

A licensed Medicare Insurance Agent or Broker is a state licensed professional able to sell Medicare plans (Part C, Part D, Medigap). Some are independent brokers, offering plans from multiple companies; others represent a single insurer.

I encouraged my sister to consult with a few licensed agents who offer plans from multiple companies, as they can offer personalized recommendations based on her prescriptions, doctors, and budget.

I explained that there is no cost for this service — the insurer pays the agents. Therefore, she should arm herself with as much information as possible before making her decision.

She could also talk to a SHIP or HICAP Counselor. They are unbiased Medicare counselors funded by federal/state programs (not affiliated with insurance companies). They do not sell insurance; meeting with them is purely educational.

I was sharing all this information with my mom, and she remarked that Medicare choices are so complicated. She asked how the average senior fares at making these choices.

I agreed with her that choosing a Medicare plan can be very difficult and confusing for the average senior, and many people feel overwhelmed by the process.

I often hear seniors say, “I don’t know what coverage I need,” or “I’m afraid to pick the wrong plan and get stuck,” and “Maybe I should go with my friend’s plan.” Of course, each policy choice is personalized to an individual’s healthcare needs, so no one should choose a plan just based upon what their friend has.

Yes, it’s confusing — but seniors don’t have to go it alone. The right help can turn a stressful decision into an informed and confident one. With help, I have faith that my sister will make the right choice for her needs.