Understanding Medicare

Medicare has been changing yearly and 2026 will be no exception. What is ahead for Medicare this fall and why?Carriers are still feeling the effects of the Inflation Reduction Act, which passed in 2022, but just took full effect in January of 2025. Beginning January 1, 2025, people with Part D plans through traditional Medicare and Medicare Advantage plans with prescription drug coverage, won't pay more than $2,000 over the calendar year in out-of-pocket costs for their prescription medications, the donut hole or coverage gap is eliminated and there is a new payment plan to spread drug costs through the year. Those changes came at a cost to other benefits. The Inflation Reduction Act significantly increased the carriers expenses and in response benefit cuts occurred for 2025 and will continue for 2026. Carriers had to absorb the steep cost increase for the mandatory prescription drug plan changes by balancing the budget, which included increases in beneficiaries copays, deductibles added to plans, the plan maximum out of pocket increased, non-medical benefits were reduced, a prescription drug deductible was added, and prescriptions were re-tiered or eliminated from the list of covered drugs. 2026 will see further adjustments as the carriers remove most benefits deemed non-medical. Seniors who have grown accustomed to benefits such as an over-the-counter allowance or food subsidy may see those benefits sharply reduced or eliminated this fall. Plans must be submitted to Centers for Medicare & Medicaid Services for approval in early spring to be ready for the enrollment period in fall to be active for the following calendar year, so carriers have had little time to study the impact of the Inflation Reduction Act on overall costs. Insurance moves slowly. The changes we are feeling in 2025 are the result of a bill passed in 2022 and will continue to affect plans in 2026. This fall will feel like a continuation of the benefit cuts seniors faced in the fall of 2024 as carriers work to balance the budget while considering the increased prescription costs and trying to maintain the plan benefits seniors rely on. For more information visit: aismedicareandmore.com Editors Note: This article was submitted by Jolynn Allen with AIS Medicare & More.  Jolynn is the owner of AIS Medicare & More and may be reached at:  719-404-3202

Congress recently made significant changes to Medicare's Part D prescription drug benefit as part of the Inflation Reduction Act. While some changes aim to help seniors afford their medications, others may have unintended consequences.On the positive side, insulin costs are now capped at $35 per month for Medicare beneficiaries. This has already provided relief for many seniors with diabetes.Starting in 2025, out-of-pocket Part D drug costs will be capped at $2,000 annually. Seniors will also have the option to spread these costs throughout the year through the new Medicare Prescription Payment Plan. These changes can benefit seniors who rely on multiple brand-name medicines or have fixed incomes.However, awareness of the new payment plan is low. Medicare could do more to inform seniors about this option, which requires opting in. Seniors should consider contacting their Part D insurers during open enrollment if they would benefit from spreading out pharmacy costs.The law's drug price negotiation provision has led to some unintended effects on drug development. At least 36 research programs and 22 experimental drugs have been discontinued as a result.Part D premiums have also increased. This year, standalone Part D plans were set to cost 21% more on average compared to last year. Many seniors switched to lower-cost options as a result. The number of available plans has decreased by about 25% since 2020.Some insurers have moved certain medications to tiers requiring higher out-of-pocket costs, restricting access to previously covered drugs. New rules like step therapy requirements have also been implemented, potentially making it harder for patients to access drugs their doctors recommend.It's important for seniors to understand these changes and their potential impacts on drug access before Medicare's open enrollment period begins in October.  Contact Carleen Lachman, Independent Insurance Specialist at 724-571-4688 to learn more.  

Health insurance jargon can be the hardest to understand for consumers. Thats why you have a broker who goes to work for you and explains your policy options with clarity. However, not all brokers work ethically. You may not have an insurance broker who values you and may not elaborate on your policy limitations. The omission of these limits is illegal and should result in the termination of that broker. In contrast, the insured typically doesnt take legal action, and the broker makes his or her desired commission.This is not to say that all health insurance brokers operate in this zone of immorality. Just as with any profession, there are good and rotten eggs. Your moral compass and ability to judge a persons intention is a significant factor people can typically smell a sleazy salesperson. Below, are the most common limitations obscurely mentioned in health insurance policies. This information should adequately equip you for when you are asking questions of your broker.Heres a screenshot from the summary of the benefits of an insurance carriers product:*Note these limitations do not exist in all policies. Ask your broker.The list of benefits above is towards the end of the policy summary. Most people are interested in seven factors when it comes to their health insurance:Deductible/coinsurance/max out of pocket, doctor visits/specialists/urgent care, the network, prescription coverage, preventative/wellness coverage, emergency room fees, and ambulatory services. If your insurance broker goes over those seven things, this is how the policy would look and sound:Choice of $500-$10,000 deductible/max out of pocket (1 million in coverage)Choice of 70/30, 80/20, or 100/0 coinsuranceUnlimited $25 copay to doctor, specialist, and urgent carePHCS Network (PPO)$50 copay for annual wellness/preventative checkupER subject to deductible and coinsuranceAmbulatory services (above) $500 per transportMost people would agree that those seven things sound fantastic for health coverage. You have all your daily doctor needs taken care of and one million dollars in coverage, right? Wrong, let me show you a scary breakdown if you had an appendectomy while being covered by this policy.On average, the Fair Price for an Appendectomy lies somewhere between $7,000 and $25,000 (may vary due to zip code). If there are complications, it could be upwards of $35,000 or more. Heres a breakdown of the services and their estimated costs. You can always check on any surgery, and its price by visiting Healthcare Bluebook.Hospital Services for a 2-day admission, itll cost roughly $9,700.Physician Services the fee for procedure and routine postoperative care costs around $1,400.Anesthesia the price for an average surgery time of 1 hour and 15 minutes costs about $750.This cost adds up to the lower end of about $11,000 for an appendectomy. If you look above at the example policy, youll see that for the entire coverage term an appendectomy will be given a $2,500 coverage benefit. Even though your plan has a deductible, coinsurance, and max out of pocket; theres a specific limitation for appendicitis. With this knowledge, the insured will be left an $8,500 bill as an out of pocket expense! Keep in mind; these numbers are on the low end with no complications.Of course, its always better to have health insurance instead of going uninsured. With insurance, that remaining $8,500 for the appendectomy may negotiate to a lower bill. Policygenius.com does a great job explaining the functionality of network negotiated rates. Without insurance, you would be paying the almost full retail price for your medical surgery, which is a terrifying thought!