My Patient Rights can help guide you in resolving issues so you can get the health care you deserve.
Medicare’s 2025 open enrollment starts October 15 and ends through December 7, 2024.
This is the time to review and assess your Medicare enrollment choices if you haven’t done it in a while or if you reviewed the options last year. The Inflation Reduction Act (IRA) has made some changes to Medicare which may affect plans, and which ones will best suit your needs. You can start with Medicare the information they provide HERE. There are several positive changes and several things to review.
In 2025, the new $2000 prescription out-of-pocket, Part D cap will start. This is automatic and you do not need to do anything to start it. However, you should note that this only affects medications you get at the pharmacy counter. Medications you receive in a provider office or infusion center are paid for under Part B and are NOT included in the cap! The cap will increase over time.
This cap also served to eliminate what was commonly called the “donut hole” which is a coverage gap where after you pay a certain amount in medication copays (in 2024 in was about $5,000), you pay full price for medications until you reach your annual out-of-pocket maximum.
Medicare Prescription Payment Program (MPPP), sometimes referred to as smoothing, allows you to spread your Part D prescription payments over the year. As an example, if you have an expensive medication or multiple medications that require a copayment that equals $1200 in one month, it might be difficult to come up with that money at the time. The MPPP allows you to pay that $1200 over 12 months (if you sign up the first month) and will be adjusted as the months go on until you reach your $2,000 cap. You must sign up for this program with your insurance company before you pick up the medication at the pharmacy counter. Should you need or be changed to an expensive medication during the year, you may join the program at any time. However, the program is reset at the end of the plan year and must be paid in that year according to your invoices. You will need to sign up again in each new policy year. Invoices will come from your insurance company, and you will send the monthly payment to them.
These changes and others in IRA mean that some of the payment burden has shifted from Medicare to your health plans. They may take steps to share that burden with you, the patient. These changes may take the form of premium and other cost increases, as well as increased prior authorization processes or formulary changes which is a list of the medications available to you. The medication you are on now may no longer be available through your insurance company or if you change insurance companies you may need to take and fail other medications before getting the one that you are currently on.
Please talk to the plan or Medicare about these potential changes. Here is a checklist of additional questions to ask your insurance company or Medicare before Open Enrollment ends.
Open Enrollment-Checklist-2025
If you are contemplating when you should sign up or want to sign up for Medicare visit this CMS page.
My Patient Rights can help guide you in resolving issues so you can get the health care you deserve.
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State and federal law protects your rights. When you sign up for a health plan and/or if you have problems accessing care through your health plan, it is important to know your rights.