Watch Phil Capriotti on The Wealth Council

Sundays @ 1PM on Fox Business

LEARN MORE
CLIENT PORTAL

Comparing Plans is Especially Important This Open Enrollment Season Due to Changes in Part D Protections and New Options

Key components of the Inflation Reduction Act’s Part D reforms will be fully implemented for plans offered in 2025. These changes, including the total elimination of the “coverage gap” coverage period, the establishment of a $2,000 cap on beneficiary out-of-pocket costs, and the creation of an optional payment plan program, together with reforms already in effect like the $35 cap on out-of-pocket costs for insulin products and the expansion of the Low Income Subsidy program (also called Extra Help), mean that it is especially important for beneficiaries to carefully compare their coverage options for next year during this year’s Medicare Open Enrollment Period.

Medicare Open Enrollment, which runs from October 15 through December 7, is when people with Medicare can preview the Part D and Medicare Advantage plans offered in their area and choose the coverage that best suits their health and financial needs and preferences. While all Medicare Advantage plans must cover all services covered by Original Medicare, and all Part D plans must provide coverage for all medically necessary Part D drugs, the costs and structures associated with plans can vary greatly and dramatically impact beneficiary access to care and financial burden.

The marketplace for Medicare Advantage and Part D plans operates on the premise that people with Medicare will compare plans during the open enrollment period to select the best coverage for their individual needs and circumstances.

KFF notes in a recent issue brief examining beneficiary behavior during open enrollment, “coverage and costs vary widely among both Medicare Advantage plans and Part D prescription drug plans and can change from one year to the next, which could lead to unexpected and avoidable costs and disruptions in care for beneficiaries who do not review their options annually. For example, changes in Medicare Advantage provider networks could mean beneficiaries lose access to their preferred doctors, while changes in the list of covered drugs and cost-sharing requirements could result in higher out-of-pocket drug costs. Further, beneficiaries’ health care needs can change from one year to the next. Even without a change made by their plan or a change in health status, beneficiaries may be able to find a plan that better meets their individual needs or lowers their out-of-pocket costs.”

Despite the importance of careful shopping and the fact that Medicare beneficiaries in 2024 will be able to choose among, on average, 43 Medicare Advantage plans and 21 Part D stand-alone prescription drug plans, the KFF analysis finds that nearly 7 in 10 beneficiaries did not compare their current source of Medicare coverage with other options in their area in 2021. Only about half of beneficiaries even checked their current plan’s coverage for changes in the upcoming year.

The structural changes brought about by the Inflation Reduction Act, especially the establishment of the $2,000 out-of-pocket cap and the simplification of the Part D coverage phases, are critical updates to limit the unpredictable, previously limitless, out-of-pocket cost burden many beneficiaries faced in previous years. These changes also highlight the importance of considering all aspects of plan design and costs throughout the year when evaluating plan options. Premiums alone may not indicate whether a particular plan is the right fit or even the least expensive option.

Changes to Extra Help implemented last year mean more people with limited incomes and assets are eligible for premium and cost-sharing assistance. Improvements to the Plan Finder tool make it easier to see plans designed to coordinate Medicare and Medicaid for those enrolled in both programs.

Additionally, the new, optional Medicare Prescription Payment Plan (MPPP) allows people to spread their Part D out-of-pocket costs over the calendar year. The availability of this program, which will likely benefit those who expect to reach the out-of-pocket cap or who take high-cost medications for limited durations, may also impact which Medicare Advantage or Part D plan is the right choice for some beneficiaries. CMS’s Plan Finder tool can show projected month-to-month costs if the MPPP is chosen.

Comparing Plans is Especially Important This Open Enrollment Season Due to Changes in Part D Protections and New Options

Share:

View the Latest Posts:

Before Your Next Appointment: 5 Medicare Questions That Can Help Prevent Costly Surprises

You schedule an appointment, hand over your insurance card, and assume your coverage will take care of the rest. Then a bill arrives—or the pharmacy tells you that your new prescription needs approval. Understanding your Medicare coverage before you use it can help you prepare for expenses, address paperwork, and ask better questions. Whether you are new to Medicare or have had coverage for years, these five questions are worth keeping handy. 1. Can I Use This Doctor With My Coverage? “Do you take Medicare?” is a starting point, but the next question depends on how you receive your benefits. With Original Medicare, you can generally use doctors and hospitals that accept Medicare throughout the United States. Ask whether the provider accepts assignment, meaning they agree to accept the Medicare-approved amount as full payment for covered services. With Medicare Advantage, you may need to use your plan’s network for non-emergency

7 Medicare Enrollment Mistakes to Avoid When Turning 65

Turning 65 is an exciting milestone—but it also brings important Medicare decisions. With multiple enrollment periods, coverage options, and deadlines to understand, even a small mistake could lead to delayed coverage, unexpected expenses, or lifelong penalties. Here are seven common Medicare enrollment mistakes and how you may be able to avoid them. 1. Assuming Medicare Enrollment Is Always Automatic Some people are automatically enrolled in Medicare Parts A and B, while others must enroll themselves. If you are already receiving Social Security or Railroad Retirement Board benefits before turning 65, enrollment may happen automatically. If you are not receiving these benefits, you will generally need to sign up for Medicare. Do not assume your coverage will begin automatically. Confirm your enrollment status before your 65th birthday. 2. Missing Your Initial Enrollment Period Your Medicare Initial Enrollment Period is a seven-month window that generally includes: The three months before your 65th

Original Medicare vs. Medicare Advantage: What Should You Choose at 65?

As your 65th birthday approaches, you will have several important Medicare decisions to make. One of the biggest is choosing how you want to receive your Medicare benefits. Should you select Original Medicare, or would a Medicare Advantage plan better fit your needs? Both options can provide valuable healthcare coverage, but they work very differently. The right choice depends on your doctors, prescriptions, budget, travel plans, and personal preferences—not simply on which option has the lowest advertised premium. Here is what you should understand before making your decision. First, What Is Original Medicare? Original Medicare is the traditional federal Medicare program. It includes: Medicare Part A, which generally helps cover inpatient hospital care, skilled nursing facility care, hospice care, and certain home healthcare services. Medicare Part B, which generally helps cover doctor visits, outpatient care, preventive services, medical equipment, and other medically necessary services. With Original Medicare, you can generally

Medicare Wellness Visits Explained: What Is Covered—and What Is Not

When you become eligible for Medicare, you may hear several similar-sounding terms: the “Welcome to Medicare” visit, the Annual Wellness Visit, and a routine physical exam. Although these appointments can all play a role in managing your health, they are not the same—and Medicare may cover them differently. Understanding the distinction before scheduling an appointment can help you ask the right questions, make better use of your benefits, and avoid unexpected costs. The “Welcome to Medicare” Preventive Visit The “Welcome to Medicare” preventive visit is a one-time appointment available during the first 12 months that you have Medicare Part B. This visit is designed to establish a baseline for your health and create a preventive-care plan. Your provider may review your medical and social history, discuss screenings and vaccines, check basic measurements, perform a simple vision test, assess certain health risks, and provide a written checklist of recommended preventive services.