The Inflation Reduction Act continues to bring changes to Medicare coverage in 2025. Though Medicare B premiums will increase, there are several significant improvements to look for. Open enrollment begins on October 15, 2024, and runs through December 31, 2024. This is an opportune time to review your supplemental and prescription plans to ensure you are maximizing the benefits most important for your healthcare needs.

Out of Pocket Spending Cap
Beginning in 2025, out of pocket spending on prescriptions is capped at $2,000 per person. The limit applies to stand-alone Medicare Part D policies and drug coverage in Medicare Advantage plans. The $2,000 cap includes deductibles, copayments and coinsurance for covered drugs. It doesn’t apply to drugs not covered by the plan, nor to Part B drugs, such as injections at doctors’ offices which may include some chemotherapy. However, this cap makes it even more important that people shop for a supplemental plan that best suits your medical needs.

Elimination of the Donut Hole
The spending cap effectively eliminates the coverage gap between the coinsurance limit and the threshold for catastrophic coverage. Under new regulations, the deductible increases to $590, followed by a 25% coinsurance up to the $2,000 cap, after which you pay no more out of pocket expenses for prescriptions in the year. This $2,000 limit is set to increase annually with inflation.

The $2,000 cap on prescription costs does not include a limit on premium expenses. Medicare recipients may see a large variation in premiums during open enrollment, as the Part D plans will now have to pick up a larger share of costs beyond the cap. Medicare will continue to negotiate on lowering prescription costs. You should have received an annual Notice of Change in September of 2024 from your Part D provider, outlining changes to your plan for 2025.

A beneficiary with high drug costs typically realizes that copay cost at the beginning of the year. The Medicare Prescription Payment Plan will now let enrollees opt to pay their prescription costs monthly rather than all at once to better budget for these annual expenses and reduce cash flow issues early in the year. You can opt into the plan by contacting your Part D company.

Coverage for Diabetes-Related Weight Loss Drugs
Medicare is prohibited from covering drugs prescribed specifically for weight loss. But Part D plans can cover popular weight loss drugs when they’re ordered for other purposes, such as type 2 diabetes, cardiovascular disease, and sleep apnea. The FDA made this approval mid-2024, so expect to see better coverage of these medications
in 2025 plans.

The Mid-Year Statement
Advantage plan recipients will receive a midyear statement listing available benefits as of yet unused for the year. Plans will now be required to notify insureds what benefits remain for them to use during the year.

Expanded Mental Health Providers
Previously, whole categories of therapists, mental health counselors and addiction counselors were prohibited from enrollment as Medicare providers. That restriction has been lifted, increasing provider eligibility to over 400,000 clinicians nationwide including telemedicine for behavioral health services to provide increased service in rural areas. providers must complete applications to become a Medicare eligible provider.

Expansion of GUIDE for Family Caregivers
2024 launched a program called Guiding an Improved Dementia Experience (GUIDE), to provide a 24/7 support line to assist caregivers in locating community-based services, caregiver training, and respite care services. GUIDE will expand 4X by July of 2025, adding almost 300 participating organizations. Services will be available to participants enrolled in original Medicare with a dementia diagnosis. There are currently two programs available in Maine, with hopefully more to
come next year.

These changes and the associated underlying costs that will affect insurance plans make it imperative to review how your current supplemental or advantage plan will change in 2025. Shop around for affordable plans that include your medications, or additional benefits that you want and need such as vision and dental. We may see plans cut coverage or pull out of unprofitable geographic areas in order to reduce the impact on the insurance company. We recommend you confirm that your providers are in your Medicare plan network as these have had changes as well. You can compare coverages and costs by meeting with your local Medicare insurance agent, an area Agency on Aging, through AARP, your state Health Insurance Assistance Program, or a number
of online resources.

As always, please contact us if we can help you navigate coverage issues with your Medicare supplemental or advantage plan or connect you with great resources in our community who can help. ■