Expensive medications? You’ll save thousands. Dementia or mental health care? More options
Key takeaways
- Changes from Inflation Reduction Act will take effect next year.
- Lower out-of-pocket limit in Part D drug plans erases old “donut hole.”
- You may find weight loss drugs covered to treat other medical conditions.
- Your Medicare Advantage plan may not stay the same.
- Look for a midyear statement from your MA plan.
- Caregivers for loved ones with dementia may be eligible for respite care.
- More mental health counselors are encouraged to enroll as providers.
You can thank the Inflation Reduction Act of 2022 for some of the biggest Medicare changes in the past few years — including a welcome reprieve from the high costs of prescription drugs.
Among the changes:
In 2023, Medicare capped covered insulin costs in Part D prescription drug plans at $35 a month and eliminated out-of-pocket costs for recommended vaccines.
In 2024, the government expanded eligibility for financial assistance from the Part D Extra Help program and announced results Aug. 15 of negotiations to reduce the costs of 10 of Medicare’s most expensive drugs. Those prices will take effect in 2026.
One of the biggest changes takes effect in 2025, when Part D plans must cap out-of-pocket spending on covered drugs at $2,000 a year. That change will have a ripple effect on Part D and Medicare Advantage plans’ other costs and coverage, making it especially important to review your options during open enrollment this year.
The Part D rules overshadow other Medicare changes that can make a difference in 2025, including Medicare Advantage midyear coverage notices and stricter marketing rules, expanded benefits for family caregivers and access to more mental health providers.
1. $2,000 out-of-pocket spending cap for prescriptions
The $2,000-a-year out-of-pocket limit for prescription medications applies to stand-alone Medicare Part D policies and drug coverage in Medicare Advantage plans.
“It’s the first time in the history of the Medicare program that people have a cap on how much they could have to pay out of pocket,” Meena Seshamani, M.D., the director of the federal Center for Medicare, said in an interview with AARP. “And such a significant change means that in open enrollment, it is so important to shop. Because with such big changes, there very well could be a plan that better suits your health and financial needs.”
The $2,000 cap includes deductibles, copayments and coinsurance for covered drugs. It doesn’t apply to premiums or to drugs a plan doesn’t cover.
“It doesn’t apply to their Part B drugs,” such as injections they get at their doctor’s office, says Gretchen Jacobson, vice president of Medicare for the Commonwealth Fund. The amount of the cap can be adjusted in subsequent years if Part D costs rise.
2. No more Part D ‘donut hole’ or coverage gap
This change simplifies the way Part D works. Before 2025, plans had four coverage phases.
- Deductible. You pay the full cost of drugs until you meet your deductible, up to $545 in 2024.
- Initial coverage with copayments that vary by medication.
- Coverage gap, which occurs when you and your drug plan reach $5,030 spent on covered medications in 2024. It was known as the “donut hole.” Plans pay less in this gap, especially for brand-name drugs, and have dispensing fees. You may pay more out of pocket for the same meds than in your initial coverage period.
- Catastrophic coverage begins at $8,000, based on your out-of-pocket costs, not the insurer’s share, and manufacturers’ discounts in the coverage gap. In the catastrophic phase in 2024, you pay nothing for your covered prescriptions until the new year, Jan. 1, 2025.
In 2025, Part D plans can have a deductible up to $590. Then you pay copayments for your medications until your total out-of-pocket costs reach $2,000.
The cap is expected to help millions of people. By April 1, 2024, more than 1.7 million people, about 3.5 percent of people covered in drug plans, had already reached $2,000 in out-of-pocket costs on their prescriptions, according to the Centers for Medicare & Medicaid Services (CMS). More certainly will surpass that by the end of the year.
People with high drug costs tend to pay a lot at the beginning of a year. The Medicare Prescription Payment Plan will let enrollees opt to pay their prescription costs monthly rather than all at once.
“This will enable people to spread out the out-of-pocket drug costs over the course of the year so that you don’t experience that sticker shock and those cash flow issues at the pharmacy,” Seshamani says.
The payment plan doesn’t reduce the total cost, but it can help with budgeting. You can opt into the plan by contacting your Part D company.
The caveat. “There was some concern that changes in the Medicare Part D benefit design that lower costs for beneficiaries, like the $2,000 cap, would lead to higher premiums for 2025,” says Tricia Neuman, executive director for KFF’s program on Medicare policy. The $2,000 cap doesn’t include premiums.
“The Inflation Reduction Act included a 6 percent cap on base Part D premiums, but the cap does not apply to the total premium that individual plans may charge,” she says. Part D plans will have to cover a larger share of the costs beyond the cap. Drug manufacturers and Medicare also contribute to the cost beyond the cap.
The 2025 Part D base premium is $36.78, but actual premiums vary depending on your location and plan.
“They [CMS officials] don’t want beneficiaries to have to end up paying more in premiums because they get a cap on their out-of-pocket expenses,” the Commonwealth Fund’s Jacobson says.
The bottom line: You may see a big variation in premiums, copayments and covered drugs during open enrollment this year. Look at the annual notice of change that your plan must send in September outlining changes to your plan for 2025.
Starting Oct. 1, you can compare coverage and costs for all the plans in your area using the Medicare Plan Finder and choose a 2025 plan during open enrollment from Oct. 15 to Dec. 7. You can get help for free from your State Health Insurance Assistance Program (SHIP).
3. More ways to get weight loss drugs
Medicare is prohibited from covering drugs prescribed specifically for weight loss. But Part D plans can cover popular weight loss drugs when they’re ordered for other purposes, such as Ozempic and Mounjaro for type 2 diabetes.
In March, the Food and Drug Administration approved Wegovy for people with cardiovascular disease who are overweight. Few Part D plans added the drug to their approved lists because they can’t change premiums midyear.
“I looked at 83 stand-alone Part D plans and 235 Medicare Advantage plans in four cities, and only two plans covered Wegovy,” says Diane Omdahl, author of Medicare for You: A Smart Person’s Guide. She’s president of 65 Incorporated in Mequon, Wisconsin, which helps people with Medicare decisions.
However, you may find more weight loss drugs covered in 2025.
“We estimate that roughly 1 in 4 Medicare beneficiaries with obesity or who are overweight could be eligible for Wegovy to reduce the risk of serious heart disease,” Neuman says. “On the one hand, Wegovy is likely to be subject to relatively high cost-sharing because of its high price, but on the other hand, Part D enrollees who take these drugs will benefit from having the new $2,000 cap on their drug expenses.”
Part D plans can expand coverage as the FDA approves other uses for weight loss drugs.
Medicare does not cover Zepbound (tirzepatide) because the FDA has approved it only for weight loss. If the agency OKs tirzepatide for treatment of moderate to severe obstructive sleep apnea and obesity, which pharmaceutical giant Eli Lilly requested, Part D plans could cover the drug for that purpose.
4. Subtle changes to your Medicare Advantage coverage
The $2,000 out-of-pocket spending cap applies to deductibles, copayments and coinsurance in the prescription drug portion of Medicare Advantage plans.
Medicare Advantage plans may make changes in 2025 to help cover their additional expenses. They are less likely than Part D plans to adjust premiums, especially if they charge nothing in addition to the Part B premium, says Meredith Freed, senior policy manager with KFF’s program on Medicare policy.
No extra premium? Probably safe. “The zero-dollar premium is really attractive to people and one of the easiest ways to compare across plans,” she says. But a plan may change its formulary, which is its list of covered drugs; reduce its out-of-pocket maximum spending limit; increase the percentage you pay for some services, called coinsurance; or reduce some of the extra benefits that drew you to the plan in the first place.
“If you still have a dental benefit, for example, maybe it’s a little less generous than in prior years,” Freed says.
The devil’s in the details. Review your plan’s annual notice of change carefully. Don’t just rely on the general description of coverage in the Medicare Plan Finder when comparing Medicare Advantage plans.
Look at the details in the Explanation of Benefits on the plan’s website before making a final decision. Also reconfirm that your providers are in the plan’s network.
5. Midyear statement from your Medicare Advantage plan
This will matter to Medicare beneficiaries who have chosen Advantage plans instead of original Medicare, 50.4 percent as of April 2024. The midyear statement will show available benefits that you haven’t used — important since those extras are often what persuades a Medicare enrollee to sign up with a particular plan.
“For example, if they haven’t used any of their dental, vision, hearing or fitness benefits, plans are required to notify them if they have any benefits left,” Jacobson says.
You’ll continue to see more realistic TV ads from Medicare Advantage plans, the private insurance alternative to original Medicare. Rules that took effect last year before open enrollment prohibited Medicare Advantage ads from mentioning benefits not available in the area where the ad appears. The ads also can’t mislead you into thinking you’re contacting a government employee when you call with questions.
6. Expanded program for family caregiver services
A program for dementia patients and their caregivers that launched this year will quadruple in 2025, serving more of the country.
The program, called Guiding an Improved Dementia Experience (GUIDE), provides a 24/7 support line, a care navigator to find medical services and community-based assistance, caregiver training and up to $2,500 a year for at-home, overnight or adult day care respite services. Patients and their caregivers typically won’t have copayments.
Adding 294 to original 96. CMS selected 96 organizations to participate starting July 1, 2024, including academic medical centers, hospitals, small and large group practices and community-based organizations already providing programs for dementia patients. The agency chose 294 organizations to join next July.
“We’re very excited about this,” says Janet LeClair, CEO of Memory & Movement Charlotte (North Carolina), a nonprofit medical practice that has focused on dementia patients for 11 years. “The caregiver is really the pivotal person ensuring the quality of life of the patients.”
Important criteria. Participants must be enrolled in original Medicare and have a dementia diagnosis. They can’t be in hospice or a nursing home.
“We know intuitively that respite is so critical to the health and well-being of the caregiver, which directly correlates to the health and wellness of the patient,” LeClair says.
To see if a program is available in your area, go to the CMS GUIDE program fact sheet and the link to the CMS Innovation website. Click GUIDE Model in the drop-down models list | Display selected.
Programs that will begin in July 2025 are listed. Contact the program to learn more about eligibility and request an assessment.
7. A push to add more mental health providers to Medicare
Although the percentage of adults 65 and older reporting they used mental health services increased by only 1 point to 20 percent from 2019 to 2022, according to a KFF study, access to care may have affected those numbers.
Before this year, licensed marriage and family therapists, mental health counselors and addiction counselors couldn’t bill Medicare because they weren’t allowed to enroll as Medicare providers. Now they can, and some have.
A paperwork process. “But it’s not just automatic. There are steps they need to take,” Freed says.
Medicare Advantage plans must meet stricter standards to improve access to behavioral health specialists.
“We’ve had such tremendous excitement and interest with tens of thousands of clinicians enrolling in the Medicare program, which will make a big difference for access to care,” Seshamani says. More than 400,000 behavioral health clinicians nationwide are eligible, but you’ll need to ask any provider you seek if they accept Medicare.
Positive development: Even though many telehealth expansions that took effect during the COVID-19 pandemic will expire at the end of 2024, Medicare permanently expanded access to telemedicine for behavioral health services. That can help with access to providers, especially in rural areas.
https://www.aarp.org/health/medicare-insurance/info-2024/medicare-changes-coming-in-2025.html
