Your guide to Medicare fall enrollment
It's important to do a check-up on your Part D or Advantage coverage each year during fall enrollment - and that's especially true this year.
It’s unfortunate that the massive privatization of Medicare requires us to go through this every year.
The annual Medicare enrollment period rolls around every fall, and that means it’s time to re-evaluate your Part D standalone prescription drug or Medicare Advantage plan. Roughly 70% don’t bother to do it - and the insurance companies that sponsor these plans hope you won’t.
You might have signed up initially for a drug plan that offered a low premium and reasonable out-of-pocket costs, or an Advantage plan that included your health care providers in its network. But plans change, so that means many Medicare enrollees are paying more than they need to - or will be surprised to find a doctor no longer is “in network.”
Neo-liberal supporters of this marketplace-based approach argue that competition holds down costs, but this is demonstrably false - especially in the case of the Medicare Advantage industry, which is overpaid by the government and taxpayers and maximizes profit through denial of care and fake “upcoding” of patient illnesses.
The situation really demands that you be your own best advocate - and that means being a smart shopper during fall enrollment, which is underway now and runs through December 7th. It’s especially true this year, as price changes will vary widely among standalone Part D prescription drug plans, with some raising premiums $50 or more.
If you are enrolled in traditional Medicare Part A (which covers hospitalizations) and Part B (outpatient visits) and have a supplemental Medigap policy, there’s no need to review that coverage during fall enrollment, which is underway now and runs through December 7th.
But the Part D insurance market is changing in the wake of the Inflation Reduction Act of 2022. The law imposed a hard cap on total out-of-pocket spending for covered drugs — it will be $2,100 in 2026.
The cap has helped protect beneficiaries who take pricey drugs for conditions like cancer and multiple sclerosis. But the insurance companies that offer plans on the Part D market have been adjusting to the greater amount of risk they are required to shoulder.
Concerned that the shift would result in much higher premiums, the Biden administration gave drug plans that agreed to participate in a special program for 2025 a subsidy. In return, plans agreed to limit monthly premium increases to $35.
The premium stabilization program will continue in 2026, but the Trump administration reduced the subsidy amounts. Next year, participating insurers may raise premiums as much as $50 per month. Plans that don’t participate can push through larger premium increases.
KFF, a health care research nonprofit, found that only a few national drug plans are raising their premiums substantially this year. Among these plans, four will charge lower premiums in 30 or more states, and two offered by Humana have reduced premiums in nearly all states.
But the monthly premium for Wellcare Value Script, the most popular plan nationally, will increase in 33 states and the District of Columbia, hold steady in 16 states and drop in two states, KFF found. Enrollees in another top plan, SilverScript Choice, will see their premiums increase by the maximum $50 in 30 states (including the District of Columbia), but reduced in 20.
Depending where you live, and your drug needs, you might even be able to choose from as many as six plans that have a zero premium.
Medicare Advantage enrollees should also be on the lookout for changes to drug coverage or to the list of in-network providers.
During fall enrollment, you can switch Advantage providers or shift to traditional Medicare — but don’t do that without first confirming that you will be able to buy Medigap supplemental coverage. (Enrollees have a guaranteed right to buy a Medigap plan during its six-month open enrollment period, which starts on the first day of the month in which you’re 65 or older and enrolled in Medicare Part B; those who apply for Medigap after that can be rejected for pre-existing conditions in most states.)
The bottom line: take a look at the Annual Notice of Change that your current Part D or Advantage plan provider sent in the mail. If the plan’s cost or coverage is changing in ways that don’t suit you, get on the Medicare Plan Finder and look for alternatives, or consult your local State Health Insurance Assistance Program, which offers comprehensive, unbiased guidance.
I examined the fall enrollment landscape in my latest Retiring column for The New York Times.
“It probably shouldn’t have the word Medicare anywhere near it”
Late night comedian John Oliver dropped a bomb on the Medicare Advantage program on his show last week. Regular newsletter readers won’t be surprised by his findings - Oliver details the misleading advertising practices, provider network and denial of care issues and upcoding that have characterized the Advantage program for years.
But as usual, Oliver brings the heat in the most hilarious way possible. Click the player above to view the segment.
ACA premiums will soar
The new pricing is surfacing for Affordable Care Act policies, and it’s an ugly picture.
ACA policies offer critical protection for people who don’t have workplace coverage - and it’s especially important for older people who don’t yet qualify for Medicare.
KFF estimates that premiums will rise 26% on average. But that doesn’t capture the true increases enrollees will face if the current enhanced premium tax credits expire. That question is at the center of the government shutdown. And resolution of the question is critical, as KFF explains:
This 26% is the increase in the amount insurers are charging, which in most cases is not what enrollees pay. 22 million out of 24 million marketplace enrollees currently receive a tax credit. The amount subsidized enrollees pay is not what insurers charge, but rather a sliding-scale share of their household income, based on a formula set by Congress. If Congress extends the enhanced tax credits, the amount subsidized enrollees pay each month will remain about the same, even though the amount insurers are charging is increasing sharply.
If the enhanced premium tax credits expire at the end of this year, KFF estimates that currently subsidized enrollees will see their monthly premium payments more than double, increasing by about 114%, on average. This reflects people with incomes below four times the poverty level receiving less financial assistance and those with incomes over four times poverty no longer being eligible for financial assistance at all and therefore being hit by a double whammy of lost tax credit and higher insurer premiums.
Reasons cited by insurers for the premium increases include rising hospital costs, growing popularity of costly GLP-1 drugs like Ozempic and the threat of tariffs.
There’s also a bit of a self-fulfilling prophecy at work. Insurers tell regulators they are increasing prices, in part, because they expect healthier people to drop their coverage if the premium tax credits expire. If that happens, the insurers’ risk pools become sicker and more costly to cover.
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