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The Inflation Reduction Act of 2022 has large implications for Medicare Beneficiaries! This article is an attempt to help our clients and community understand what to expect in 2025 regarding changes to Medicare Part D and what your user experience might be. First, if you are receiving Extra Help with Prescriptions, or Low-Income Subsidy (LIS), you need not worry about the cost of your prescriptions increasing! As of January of 2024, the Inflation Reduction Act expanded eligibility guidelines for the LIS program through Social Security to include all those on Medicare with incomes below 150% Federal Poverty Level (FPL). In 2024, you will qualify for Extra Help if your income is as much as $22,596 per year, if you are a single person, or $30,660 if you are a married couple. When you qualify for Extra Help with Prescriptions, benchmark premiums and Deductibles are waived, while Co-pays, and Coinsurance for Prescriptions are limited to very low set amounts each year. You also may qualify for certain Medicare Advantage plans that may provide $0 copays for all your medications. If you are not qualified for Extra Help with Prescriptions and you take insulin, insulin is dependably affordable! The Trump Administration began the $35 cap on insulin in 2020 , through the Insulin Savings Model. The IRA expanded the insulin cap to include all formulary insulin and to include not only insulin covered through Part D, but also through Part B. As of 2023, the IRA makes it possible for you to get your Medicare covered vaccines at $0 cost at the pharmacy. Please remember to get your vaccines at the pharmacy and NOT the doctor’s office. When you get a prescription from the pharmacy, it will be covered under Part D. When you get the same shot administered by your doctor, in the doctor’s office, it will be covered under Part B. Part B medications have a 20% cost share to the beneficiary. If you typically fall into the “Donut Hole” and enter the Catastrophic Phase of drug coverage, you should pay less for your prescriptions in 2025. Due to IRA, a person on Medicare in 2024 who reaches the Catastrophic Phase of drug coverage will pay $0 for all their covered medications. To reach the Catastrophic Phase of coverage, in 2024, an individual would pay about $3250 in actual out of pocket costs. So you will probably experience significant less cost in 2025 due to IRA’s Part D Redesign and $2000 out of pocket maximum. However, most people on Medicare do not fall under any of the above categories! Many take no prescriptions, few low-cost maintenance drugs, or just one name brand that might put them into the “Donut Hole” but not into the Catastrophic Phase. On average, most people on Medicare pay much less than $2000 out of pocket for their drugs each year. If you are on Medicare and have low utilization of Part D- meaning you may take no medication or just a couple maintenance medications, or just one expensive brand that might have put you just over the edge of the “Donut Hole” in 2024- You will likely pay more for your prescriptions in 2025! Because the IRA transfers most of the prescription cost from the government to the Drug Manufacturers and the Insurance Carriers, we will see a lot of changes in our Medicare Plan Options for 2025: · There will be fewer Part D plans. · There will be less generous supplemental benefits on Medicare Advantage Plans such as dental to help pay for the insurer’s increased prescription cost. · There will probably not be any $0 Premium Plans. · You will probably have a drug deductible on T3 and above medications. · You will probably have coinsurance rather than a copay for most T3 and above medications. · Formularies may be tighter, meaning some drugs may or may not be included. · More costly prescriptions will probably have higher utilization controls, meaning prior authorization, step therapy, etc… · Medicare Advantage with Prescription Drug Coverage will probably be more cost effective for certain beneficiaries experiencing higher out of pocket cost in January. For more information about how the Inflation Reduction Act may affect your Medicare coverage in 2025, please contact Senior Benefit Advantage, LLC. Senior Benefit Advantage is an Independent Insurance Brokerage owned and operated by Rhonda Kraus, MSW and Licensed Insurance Agent/Broker. Rhonda’s social service background coupled with more than 35 years of insurance industry experience is the foundation of Senior Benefit Advantage. She and her team strive to be a valued resource to their clients in the communities they serve. For more information or questions about your Medicare, please visit their website: seniorbenefitadvantage.com or call 740-502-2784.
Attention: Medicare Beneficiaries This year’s Annual Enrollment is going to be the busiest since The Modernization of Medicare Act that began in 2006, when Prescription Drug Coverage was enacted, and Medicare Advantage was expanded. The Inflation Reduction Act (IRA) of 2022 has introduced more changes to Medicare than at any other time since then! You will likely see an impact on your premium and plan benefits, resulting from the new rules. The changes IRA has made to Prescription Drug Coverage (Part D) may cause premiums to be higher, drug formularies to be slimmer, and utilization measures such as prior authorizations and step therapy for certain medications to be more common. Your cost share for prescriptions, meaning deductibles, copays, and coinsurance may also be higher. Annual enrollment begins each year on October 15th and ends on December 7th. This year your annual notice of change will contain information regarding the new rules and changes to drug coverage in 2025. How do the changes affect you? If you are a Medicare beneficiary who typically pays more than $2000 in the year for your covered prescriptions- you will not pay more than $2,000 for all your covered prescriptions in 2025! However, if you are a Medicare beneficiary who pays less than $2,000 for covered prescriptions, you may pay more for your prescriptions in 2025 due to fewer plan choices and higher cost share on some plans up to the $2000 limit. As part of the new law, there is a new program being implemented called the Medicare Prescription Payment Plan (M3P) that is intended to help a Medicare beneficiary “smooth” the cost of medication throughout the year rather than having to pay all costs upfront at the pharmacy. What to do: Carefully read and assess the changes to your Medicare plan in 2025. You will receive your Annual Notice of Change (ANOC) letter in September from your current insurance carrier. If the changes to your plan are not acceptable to you, please call your broker as early as possible to make sure you can get the help you need within the allotted 54 days from 10/15-12/7. Come to the Senior Benefit Advantage educational meetings at the following locations: Coshocton Village Inn and Suites: · Wednesday 9/18 at 10 am, and 2pm · Wednesday 9/25 at 10 am, and 2pm Coshocton County District Library: · Monday 10/7 at 10:30 am Our Mission at Senior Benefit Advantage: At Senior Benefit Advantage, we strive to be a source of information to our clients and our community regarding changes to Medicare and the impact those changes may have on you. It is our mission to be a valued resource to our community as an agency specializing exclusively in Medicare Products and services.
“Of all the questions I get from my clients- Drug Coverage is usually their biggest concern! At Senior Benefit Advantage, we help our clients better access their medications through connecting them to programs that make their prescriptions more accessible and affordable to them. We also strive to be a source of information to our clients and our community regarding changes to Medicare and the impact those changes may have on you.” – Rhonda Kraus (Owner and Director of Client Services of Senior Benefit Advantage, LLC.) The Road So Far and What Lies Ahead Let’s start with what we know about Medicare Drug Coverage today. In 2024, Part D coverage consists of four phases: the deductible phase, the initial phase (co-pay phase), the coverage gap (donut hole) phase, and the catastrophic phase. During the Coverage Gap or donut hole phase, someone taking a costly brand name drug would pay 25% for that drug while in the donut hole. Once their total drug cost reaches $8000, also known as TrOOP (True Out of Pocket) cost, they exit the donut hole and enter the Catastrophic Phase. In 2024, all prescriptions in the Catastrophic Phase cost $0 copay. Medicare beneficiaries who qualify for Extra Help and Low-Income Subsidy are not subject to the coverage gap, their Part D premiums are subsidized, and deductibles are waived. In anticipation of plan year 2025, there is a lot of buzz about the impact of the Inflation Reduction Act of 2022 on Drug Coverage and what plans in 2025 will look like as a result. The Inflation Reduction Act (IRA) has imposed a maximum out-of-pocket limit (RxMOOP) – that a person will pay each year for Medicare Part D prescription drugs covered by their Part D drug plan (either a stand-alone Medicare Part D prescription drug plan, (PDP) or Medicare Advantage plan that includes drug coverage, (MAPD). In 2025, the RxMOOP limit is $2000. The RxMOOP limit can change year to year based on inflation and economic conditions. Of course, we will not know until October 1st what the new plans will look like, but I can share with you some basic facts regarding the new drug coverage rules being implemented in 2025 from the Inflation Reduction Act (IRA). The New Rules for 2025 Drug Coverage In 2025, Part D Coverage will consist of 3 phases: Deductible Phase. Initial Phase, and Catastrophic Phase. The standard Drug Deductible in 2025 will be $590. During the Initial Phase, a beneficiary will pay 25% of the cost of the drug, and when their out-of-pocket costs reach $2000, they will enter the Catastrophic Phase and pay $0 for their prescriptions for the remainder of the year. There will no longer be a Coverage Gap and Medicare beneficiaries will not pay more than $2000 for prescriptions in 2025. They will also have the option of spreading their prescription cost evenly throughout the year via a new program called the Medicare Prescription Payment Plan. The Medicare Prescription Payment Plan is a program in which CMS is mandating the insurance carriers (Plan Sponsors) to pay your pharmacy bill up front and bill you each month on a pro-rata basis that divides the amount you owe for prescriptions up to $2000 (RxMOOP) by the number of months left in the year. This program is optional for every Medicare Beneficiary and can be opted into or out of at any time of the year. It is credit, and if someone defaults, it will be collected as medical debt. An individual participating in this program will not be disenrolled from their insurance plan if they fail to pay. However, after a two-month grace period, they can be disenrolled from the Medicare Prescription Payment Plan. I am sure you will start to receive a lot of information regarding the new rules and changes to Drug Coverage in 2025 around September this year. Senior Benefit Advantage will be announcing Educational Meetings regarding Drug Coverage in 2025 to be held at the Village Inn and Suites and, also the Coshocton Library. Please stay tuned for dates and more information! As Always- Thank you for choosing Senior Benefit Advantage as your Local Medicare Advisors! Sources: https://www.cms.gov/newsroom/fact-sheets/final-cy-2025-part-d-redesign-program-instructions-fact-sheet https://q1medicare.com/index.php?utm_source=partd&utm_medium=q1mimg&utm_campaign=header
If you need Medicare Extra Help, we are here for you. Learn more about Extra Help and the importance of the month of September when navigating Extra Help.
If you need Medicare Extra Help, we are here for you. Learn more about Extra Help and the importance of the month of September when navigating Extra Help.
If you need Medicare Extra Help, we are here for you. Learn more about Extra Help and the importance of the month of September when navigating Extra Help.
Let’s face it, although Medicare Advantage is a great option- it is not the only option- and it is NOT ALWAYS THE BEST OPTION!
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