Benjamin Franklin has a famous quote, “Nothing is certain except death and taxes”. If he were alive today he may have also added “…and changes to Medicare”. Medicare is a benefit from paying into the Social Security taxes during our working careers. Unfortunately, it is not a “set it and forget it” situation. Every year as new rules and policies are implemented, it is very important to be familiar with how the new changes may affect your care and costs.
Although we are still only halfway through 2024, we already know of new changes in Prescription Drug Plans set to begin next year. The most notable is the elimination of the Coverage Gap, commonly known as the “Donut Hole”. Medicare beneficiaries will now see an annual cap of $2,000 on out-of-pocket spending for prescription drugs. While this is great news for many who have expensive drug costs, it is likely going to result in higher costs for Prescription Drug Plan (PDP) premiums. There will also be improved access to generics and biosimilars, so we can anticipate some changes in the specific drug brands that will be included in PDP formularies. One way or another the insurance companies will be making changes to adjust to the new higher costs. This may be a very important year to verify your PDP plan is still right for your specific needs and preferences.
When it comes to Medicare Advantage Plans, one of the main concerns is complaints regarding prior approval. When you stay on Original Medicare, your doctor can approve whatever procedures he recommends. This is not the case with Medicare Advantage Plans. Prior approval is needed from the insurance company. Your doctor is no longer your “gatekeeper” regarding prior authorizations, it’s the insurance company. However, be aware recent studies have shown that as low as 30% of appeals are overturned and prior years’ studies have shown up to a 75% approval of appeals. So, if your doctor tells you that their request for prior approval was denied, tell them to appeal the decision. There is a good chance the appeal will be granted. Lastly, most of the problems with prior authorization denials have been in rural areas where there are few doctors and hospitals. This problem has been noted by members of Congress and they are working on improving the situation.
If you are reading this article because you will soon be aging into Medicare, my strongest advice to you is to not procrastinate on applying for Medicare (you should submit your application to ssa.gov 3 months before the month you turn 65) as well as decide whether you will choose a Medicare Advantage Plan or a Supplement Plan. There is a lot to consider, but you have a local connection (not an 800 number) that can help you navigate which plan works best for your situation. Feel free to reach out to us at any time. Our services are free, and we are always happy to help. Reach me, Christian Regalado, at (850) 687-7606 or email christian@evergreenhealthins.com.
Author: Sowal Editor
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