Category: Medicare

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Medicare

Medicare Releases Updated Costs for 2025…premiums increase by 1%

CMS (Centers for Medicare and Medicaid Services) has released the new costs for premiums and deductibles for 2025 Medicare coverage. Each year, costs are adjusted, deductibles and premiums re-set and released to the public. For the 2025 plan year the following costs will be in place for Original Medicare:

Part A Deductible: $1676 per hospital admission (unless within the same 60-day period)

Part B Premium: $185.00/month

Part B Deductible: $257/year

Part B Coinsurance: 20% (remains the same)

Part D Deductible: $590/annual– paid before prescription drug cost share begins**

Part D Initial Drug Phase: up to $2000 in out-of-pocket expenses

IRMAA – applies to single HH earning $106K or married HH earning $212K

Social security COLA Increase for 2025: 2.5%


**NEW for 2025 – There is a new Medicare Payment Plan M3P available to help spread out the costs of your prescription medications over a 12-month payment plan. Members of plans can enroll in the Rx Payment Plan beginning December 8 – 31 for Jan 1 2025 start. Enrollment in the payment plan is optional and administered directly by your MAPD/PDP carrier (NOT your pharmacy). Enroll directly with your carrier between December 8-31.

***NEW for 2025 – The Gap or Donut Hole phase of the Medicare Prescription Drug Plan has been eliminated for 2025. Catastrophic phase begins once you have incurred $2000 in out-of-pocket drug costs. Costs go to $0 during the Catastrophic phase. 2025 Drug plans now have 3 phases: Deductible, Initial, Catastrophic.

For most Rx plans in 2025:

Deductible: $590
Initial Phase: 25% cost share for medications until you reach $2000 in costs
Catastrophic: $0

Medicare resets its costs annually. These changes will take place beginning January 1, 2025 through December 31, 2025.

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Medicare

These are the first 10 Drugs Medicare has negotiated pricing for

There have been a lot of changes underway with Medicare as a result of the Inflation Reduction Act signed in August 2022 by President Biden – the law expands Medicare benefits, lowers drug costs and has been enacted with the goal of improving the viability of the Medicare program for generations to come.  Short term, the law will help with reducing prescription drug costs.  A debilitating issue for so many on Medicare. 

A major aspect of the new law provides medicare the ability to negotiate drug prices directly with manufacturers to help gain control of the spiraling costs consumers are subjected to with many name brand medications. 

Now, we have the first 10 medicines that will be subject to Medicare price negotiations:

Januvia – Diabetes 
FIasp   –  Diabetes 
Novolog – Diabetes
Farxiga  – Diabetes, Heart Failure, Kidney Disease
Enbrel – Rheumatoid Arthritis, Psoriasis
Jardiance – DIabetes, Heart Failure, Kidney Disease
Stelara  –  Psoriasis, Crohn’s Disease, Ulcerative Colitis
Xarelto – Blood clots, coronery or peripheral artery disease
Eliquis – blood clots
Entresto – Heart Failure
Imbruvica – Blood Cancers

On average the cost reduction is approximately 60% with many higher and a few lower.  New pricing will begin January 1, 2026.  The new pricing is forecasted to save consumers an estimate $1.5 Billion in out of pocket costs and approximate $6 Billion to the Medicare program savings.  Negotiations began in February 2024 and concluded August 2024.

In other areas of impact on Medicare, the Inflation Reduction Act has already capped the cost of most insulins at $35 a month in 2024.  Beginning in 2025, out-of-pocket drug costs for Medicare recipients will be capped at $2000 a year.  In addition, for the first time, Medicare is offering a payment option to help offset the high deductible phases and upfront costs for many and pay over a 12-month period. 

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Medicare

Sweeping Changes to Medicare Prescription Drug Plans in 2025

The Centers for Medicare and Medicaid (CMS), the federal agency that administers the Medicare program, announced sweeping changes to Medicare Prescription Drug plans for 2025.

Many of these updates are a direct result of the Inflation Reduction Act of 2022, a landmark United States federal law, which had a key provision to lower the cost of prescription drug prices.

Part D Prescription Drug Cost Share has been streamlined to 3 phases:
Annual Deductible – in 2025 the deductible is $590 (some plans will have a $0 deductible). You pay 100% of drug costs until deductible is met.
Initial Coverage – 25% co-insurance on medicine costs
Catastrophic Coverage – $0 med costs once your costs reach $2000

Medicare is capping your out-of-pocket costs for prescription medicines at $2000 in 2025!!!! This is a game-changer.

Medicare Prescription Payment Plan (M3P):

For the first time, Medicare will allow you to pay your out-of-pocket prescription medicine costs in monthly amounts spread thoughout the 2025 plan year, rather than paying your full cost share at the pharmacy. With this program, you will pay the carrier direct through a monthly bill/payment plan. And will pay nothing at the pharmacy. Medicare enrollees should contact their carrier directly to enroll in the program before January 1, 2025.


Enrollees can opt out of the program at any time. However, they will continue to be billed monthly for any cost-sharing amounts still owed.

Failure to pay will result in disenrollment from the prescription payment program (not the plan) after a specified grace period. Once an enrollee leaves the program they will resume their out of pocket cost sharing at the pharmacy.

What counts towards the $2000 maximum Out-of-Pocket???

Any money spent during the deductible and initial coverage stages will apply. Premiums for prescription drug plans will NOT apply.

As a result of this change, plans will modify their formularies, so it is important to re-look at your prescription drug coverage and make sure your medicines are on the plan formulary.

Remember, Annual enrollment begins October 15 – December 7. You can set up an appointment beginning October 1 to look at new plan costs and formularies. All of the new changes will take effect beginning January 1, 2025.

To set up an appointment for Annual Enrollment Period Click Here

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Medicare

A Guide to Managing Healthcare for Aging Loved Ones

As our loved ones age, managing their well-being and healthcare becomes critical. Among the myriad of considerations, and often overlooked, the type of Medicare coverage you choose can make or break you. From chronic conditions to financial resources, to the level of independence your loved one has, there are so many variables to consider.   Let’s face it.  It’s not easy.  And the level of care needed can fluctuate on a moments notice.  The challenges can seem never-ending.

How do you cope?  Where do you turn?  What do you do?  Let’s break it down:

Critical Issues to Consider:

  1. Age and Health Issues: Aging often brings about various health challenges that require specialized care and attention.  Plan accordingly.
  2. Chronic Conditions and Medications: Chronic conditions such as diabetes, heart issues, cancer and neurological diseases require consistent monitoring and treatment. Evaluating the required medications and their coverage under Medicare plans is essential for effective cost management.
  3. Independence and Activities of Daily Living (ADLs): Assessing the individual’s ability to perform daily activities independently is crucial. Depending on their level of independence, additional support or specialized care may be required.
  4. Financial Resources: Financial considerations play a significant role in determining the most suitable Medicare coverage. 
  5. Transportation Needs: Access to transportation is vital for attending medical appointments, acquiring medications, and engaging in social activities. Can your loved one drive?  Use public transportation, or access an uber? 

Chronic Conditions: Managing chronic conditions is challenging.  Managing someone else’s chronic condition only compounds the difficulty.  Let’s take a look at some of the most common ones:

  1. Diabetes: Diabetes requires regular monitoring of blood sugar levels, medication adjustments, insulin shot management and lifestyle modifications. Individuals with diabetes may need to see an endocrinologist, a podiatrist for foot care, an ophthalmologist for eye exams.  
  2. Cardiovascular Health: Heart disease necessitates close monitoring of blood pressure, cholesterol levels, and heart function. Patients may require visits to cardiologists for specialized testing (e.g., echocardiograms, stress tests) and interventions (e.g., cardiac catheterization, pacemaker implantation).
  3. COPD: Conditions like COPD or asthma may require consultations with pulmonologists for pulmonary function testing, bronchodilator therapy, and oxygen therapy management. 
  4. Cancer:  From oncologist visits to hospital visits to radiation, chemotherapy, and medication management, we all know this treatment protocol takes alot of support and time.  
  5. Kidney Disease:  Advanced kidney disease requires dialysis – which typically involves visits 3 times weekly to dialysis clinics for 4-6 hours at a time.  
  6. Arthritis and Musculoskeletal Disorders: Individuals with arthritis or musculoskeletal disorders need a rheumatologist or orthopedic specialist for pain management, joint injections, physical therapy, and surgical interventions if necessary.
  7. Neurological Conditions: Neurological disorders such as Parkinson’s disease, Alzheimers or multiple sclerosis may require visits to neurologists for symptom management, medication adjustments, and coordination of care with other healthcare providers.

None of the above chronic conditions are easy to manage.  Knowing the types of doctors you need to see for each condition is a good start.   Making a detailed list of prescription medications, dosage (mg),  and number of doses a day required, is another must have.  While you are making that list, make one of all the doctors your loved one has and what condition they treat.  Also document which doctor is prescribing each medication.   Keep this file current and easy to access.  

MANAGING HEALTHCARE DECISIONS 

First word of advice.  If you re going to be making healthcare decisions for your loved one, get a Durable Medical Power of Attorney

You can find sites online to download a durable medical power of attorney (POA) form if you wish do-it-yourself. However, even if you prepare your own medical power of attorney document, it’s always smart to consult with an estate planning attorney who can tell you which documents you will need for your particular situation and needs.

Having a Medical POA is critical as it removes decision-making barriers for healthcare. In situations where immediate decisions are required, having a designated individual with Medical POA ensures timely and appropriate medical care without legal barriers.  It also allows you to handle medicare coverage decision making, and control how you will cover the healthcare costs.

MEDICARE MATTERS…alot

There are alot of options (potentially) when it comes to Medicare coverage. 

However, there are a few not so well-known facts about Medicare coverage:

Plan availability is county-specific

You must have Part A & Part B to qualify for a Plan C

Having a Drug Plan is mandatory

There are three options for medicare coverage

 

 

 

 

 

Essential Resources:

  1. Medicare.gov: A comprehensive platform to explore available Medicare plans in the market, compare coverage options, and make informed decisions.
  2. Social Security Administration (800-772-1213): Contacting the SSA assists in setting up Medicare Parts A and B, ensuring seamless enrollment into the Medicare program.
  3. CMS – Medicare (1-800-633-4227): The Centers for Medicare & Medicaid Services provide valuable information and assistance regarding Medicare coverage, eligibility, and enrollment.
  4. Local Center for Aging: Every county typically has a Center for Aging or similar organizations that offer support and resources tailored to the needs of aging individuals and their caregivers. These centers provide guidance on Medicare, healthcare options, and community support services.

Conclusion: Navigating Medicare for a parent or relative involves careful consideration of various critical factors such as age, health issues, financial resources, and legal arrangements. By understanding these aspects and utilizing essential resources, caregivers can ensure that their loved ones receive the necessary healthcare coverage and support tailored to their needs. Establishing a Medical POA further streamlines decision-making processes, ensuring prompt and appropriate medical care when needed. With the right information and support, managing Medicare becomes a manageable task, promoting the health and well-being of aging loved ones.

 

 
 
 
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Medicare

Which gets Medicare? The Difference Between SSI and SSDI.

When it comes to navigating eligibility for Medicare benefits, two terms that often come up are SSI and SSDI. While they may sound similar, they are distinct programs with different eligibility criteria and purposes. Understanding the differences between Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) can be crucial for individuals seeking financial support due to disabilities. Let’s delve into these two programs and explore how they differ.

What is SSI?

Supplemental Security Income (SSI) is a federal program designed to provide financial assistance to disabled individuals who have limited income and resources. It is a needs-based program, meaning eligibility is determined based on financial need rather than work history. SSI benefits are intended to help individuals meet their basic needs such as food, shelter, and clothing.

To qualify for SSI, applicants must meet the following criteria:

  1. Limited Income: Applicants must have limited income, which includes earnings, pensions, and other sources of financial support.
  2. Limited Resources: Individuals must also have limited resources, including cash, savings, and assets such as property and vehicles.
  3. Disability: Applicants must have a disability that prevents them from engaging in substantial gainful activity (SGA) and is expected to last for at least 12 months or result in death.

What is SSDI?

Social Security Disability Insurance (SSDI) is another federal program that provides benefits to disabled individuals. Unlike SSI, SSDI is based on work credits earned through employment and is not strictly income-based. Individuals who have worked and paid Social Security taxes for a certain number of years may be eligible for SSDI benefits.

To qualify for SSDI, applicants must meet the following criteria:

  1. Work Credits: Applicants must have earned a sufficient number of work credits by paying Social Security taxes through their employment history. The number of work credits required depends on the individual’s age at the time they become disabled.
  2. Disability: Applicants must have a disability that meets the Social Security Administration’s (SSA) definition of disability, which is similar to the criteria for SSI.

Connection to Medicare

One significant difference between SSI and SSDI is the connection to Medicare. Individuals who receive SSDI benefits are eligible for Medicare coverage after a waiting period of 24 months from the date they become entitled to SSDI benefits. This means that SSDI beneficiaries have access to healthcare coverage through Medicare, which can help alleviate the financial burden of medical expenses.

On the other hand, individuals who receive SSI benefits typically do not qualify for Medicare. Instead, they may be eligible for Medicaid, which is a separate program that provides healthcare coverage to low-income individuals and families. Medicaid eligibility varies by state, and recipients may receive assistance with medical expenses such as doctor visits, prescription medications, and hospital stays.

While both SSI and SSDI provide financial assistance to disabled individuals, they differ in eligibility criteria and the connection to healthcare coverage. SSI is a needs-based program that is income and resource-sensitive, whereas SSDI is based on work credits earned through employment. SSDI is the only one that qualifies you for Medicare Parts A & B Benefits after a 24-month period.Understanding these distinctions can help individuals determine which program they may be eligible for and navigate the process of applying for Social Security benefits effectively.

 

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Diabetes? Here’s what you should know about Medicare

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