Everybody who is on Medicare should reassess insurance coverage during the open enrollment period from Oct. 15 through Dec. 7.
The changes can add up to a lot of money and uncertainty, so it’s important to check every year during open enrollment to see if the plan you have is the best one for next year, instead of auto-renewing. There could be little surprises — or big surprises — all over the place, yet only a third of Medicare enrollees re-assess their coverage, the health policy research organization KFF found.
In traditional Medicare, there might be significant changes for a Part G supplemental plan, or Medigap. The premiums alone can vary widely; offerings for me range from $301 to $511 monthly.
Part D drug plans might also change a lot this year (see below for details).
Enrollees in Medicare Advantage, the privatized version of Medicare, could see the largest changes. Enrollees will have, on average, a choice of 34 Medicare Advantage plans with drug coverage — which is often included in the Medicare Advantage package — to choose from in their county for 2025.
This year, a surprisingly large number of people will not be able to ignore open enrollment because their plans are vanishing.
“More than 1.8 million Medicare Advantage members, or roughly 8% of those in non-group, non-special needs plans, are enrolled in policies that won’t be offered in 2025, according to an Oliver Wyman analysis. About 1.3 million of them are currently enrolled in $0 premium plans,” CNN wrote. “They will have to actively select new plans, or they’ll be placed in traditional Medicare. By comparison, roughly 230,000 members, or about 1%, were in this situation for 2024.
The marketing blitz
What you’re about to encounter if you’re anywhere near Medicare age is the annual marketing blitz, in your mailbox and on the web and TV, on the sides of buses and just about everywhere else. In case you find Medicare Advantage tempting, with Joe Namath and all the others selling these plans hard, think twice and listen to Wendell Potter, the former insurance executive turned gadfly/whistleblower.
In his recent newsletter at Healthcare Un-Covered, he writes about the topics that don’t get mentioned in Medicare Advantage promotional materials:
“Delays and denials – Unlike traditional Medicare, private Medicare Advantage insurers often overrule patients’ physicians and refuse to pay for medically necessary care. …It has been documented by the federal government’s Office of Inspector General and other agencies. Insurers maintain a long list of tests, treatments and medications that require ‘prior authorization,’ meaning doctors have to ask Medicare Advantage insurers for permission in advance … Prior authorization is almost never used in traditional Medicare.
“Inadequate provider networks – Private Medicare Advantage plans maintain proprietary and often very limited ‘networks’ of doctors, hospitals and labs and typically refuse to cover care by providers that are not included in those networks. Networks don’t even exist in traditional Medicare. …
“Potentially high out-of-pocket expenses – If you’re in a Medicare Advantage plan, especially a Medicare Advantage HMO, you could be on the hook for thousands of dollars out of your own pocket if you go to a doctor or hospital that’s not in your insurer’s network. In some counties, Medicare Advantage plans limit your access to doctors and hospitals who are in your county of residence. If you want to go to a specialist or center of excellence in another part of the country or even across the county line, you better have a lot of money in the bank.
“Entrapment – Once you’re lured into a Medicare Advantage plan, good luck being able to escape the Medicare Advantage world – ever. While your Medicare Advantage insurer can decide to leave your county whenever it wants … you will have a hard time getting into traditional Medicare and buying a Medicare supplement policy to cover your out-of-pocket expenses. You can buy a Medicare supplement policy without going through medical underwriting during your first six months of eligibility for Medicare benefits. But if you enroll in a Medicare Advantage plan and miss that window, you likely will have a hard time finding an affordable supplemental plan, especially if you have any medical issues or ‘pre-existing conditions.'”
New drug plan options
As every year, Medicare Part D drug plans will change, some by a lot. So it’s worth seeing if your spending will change.
Keep an eye out for small changes — a change in a deductible, or a change from a fixed charge for generics to a percentage charge. Little things can add up.
Also look for bigger changes: Part D premiums will go up sharply for Medicare recipients who live in Alaska, California, Connecticut, Massachusetts, New Jersey, New York, Rhode Island and Vermont. They have been paying low premiums for Part D.
TheStreet reports on these price increases for Wellcare Value Script coverage, assuming two generic blood pressure drugs:
“New York: The total 2024 annual premium was $44.40. In 2025, it will be $464.40, an increase of 946%.
“Rhode Island: The total 2024 annual premium was $6. In 2025, it will be $148.80, an increase of 2,380%.
“Vermont: The total 2024 annual premium was $6. In 2025, it will be $148.80, an increase of 2,380%.”
For me, in New York State just outside of New York City, premiums go up to $38.70 a month from $7 a month. It does start to make those Medicare Advantage plans with a $0 premium and free Part D look good, and I guess that’s the point.
Keep in mind that it’s possible that getting meds for cash from someplace like Mark Cuban Cost Plus Drugs might save a lot. My Part D resulted in higher prices than I would pay on cash for many of my medications, which are almost all generic. So I buy a lot of my medications via mail order at inexpensive prices from Mark Cuban Cost Plus Drugs. Details here.
In my case, I have a few generics that I buy from there, for big cost savings, so i usually go for the plan with the lowest premium. So why keep a Part D plan? Because there’s a penalty if you decide you don’t need it now, then pick it up later.
New drug plan
Should you consider the new Medicare Prescription Payment Plan, which is supposed to even out drug costs? The bottom line is, maybe. It requires some serious analysis of your current spending.
The idea is “smoothing” drug costs, Richard Eisenberg writes over at Fortune Well. “Since Medicare will cap out-of-pocket Part D prescription costs at $2,000 in 2025 (the cap doesn’t apply to prescriptions not covered by your plan; Part B medications received at a doctor’s office; or Part B medical devices like continuous glucose monitors), you might think that M3P would just even out your maximum outlay at $167 every month, which is $2,000 divided by 12.
“You’d be mistaken. Instead, the rolling formula all Part D plans will use for monthly bills of people with M3P is this: What you would have paid for any prescriptions that month plus your previous month’s balance divided by the number of months left in the year.
“That means your monthly cost will vary depending on which prescriptions you’ve taken, how regularly, when you started them, whether you stopped them and how much they cost.
What you can do
Our full story on how to choose Medicare coverage is here.
For all questions about Medicare, your state or city should have a SHIP hotline — the State Health Insurance Program, which gives impartial advice. Use it. The one in New York City is great; one in our suburban Westchester locale did not return a call. Some states use a different name for this umbrella program; in New York it is HIICAP.
From the SHIP website: “SHIP is a free health benefits counseling service for Medicare beneficiaries and their families or caregivers. SHIP’s mission is to educate, advocate, counsel and empower people to make informed healthcare benefit decisions. SHIP is an independent program funded by Federal agencies and is not affiliated with the insurance industry.
“SHIP Counseling is FREE of charge. State Health Insurance Assistance Programs (SHIPs) provide free help to Medicare beneficiaries who have questions or issues with their health insurance. You can call a counselor or attend a workshop/presentation in your area.”
Some people swear by brokers; others swear at them. We usually point out to people that brokers, however affable and seemingly well–informed, are incentivized to sell you the policy that works best for them (read commissions) and maybe not the policy that will work best for you.
Medicare Savings Programs, a series of little-known programs, help Medicare beneficiaries in the low- and middle-income brackets pay premiums, such as your Part B premium, and other costs. They are joint federal-state programs, so they have different guidelines by state. The savings could be substantial — allowing someone to get on traditional Medicare with or without Medigap, rather than going for Medicare Advantage. Learn more here and here. States vary widely: New York, for example, recently expanded eligibility.
Similarly, the federal Qualified Medicare Beneficiary (QMB) program pays Medicare Part A and B premiums and cost-sharing for older people with low incomes. This is managed at the state level, and a lot of people don’t know about it — both people who qualify and doctor’s offices sending bills. Read more here.
Want to go deeper? There’s a book for that: “Get What’s Yours for Medicare,” by Philip Moeller. It’s part of a series including “Get What’s Yours for Social Security,” by Moeller, Laurence J. Kotlikoff and Paul Solman.
There’s a hotline at the Medicare Rights Center: Call (800)-333-4114.
There’s a lot of data on the Medicare Plan Finder, the government website that posts Medicare, Part G, prescription drug and Medicare Advantage plan offerings.
