Category: Medicare

Categories
Part D Prescription Drug

Part D Sticker Shock

I heard from a client who had just returned from picking up and paying for a tier 4 medication at her pharmacy and was shocked at the co-payment of $837.73. She knew her Part D drug plan has a deductible on higher tier medications, meaning she pays the full amount of the drug cost up to the deductible amount, and that higher tier medications have higher cost sharing. Still, she asked “I was able to pay this but how are other people supposed to come up with $800 on the spot?”

Medicare Prescription Payment Plan (PPP)
Click image for page 83 “Medicare and You 2026”

I mentioned that the PPP allows individuals to spread that high cost of their Medicare Part D prescription drugs over the rest of the year; as monthly payments instead of all at once. A few points on this:

  • This payment plan applies only to covered Part D drugs – not Part B medications administered in a doctor’s office.
  • The M3P is voluntary and so enrollment is not automatic. If you want to spread those higher costs out in installment payments, you must opt-in by contacting your plan’s customer service number provided on your 2026 plan ID card.
  • Beginning January 1, your pharmacist is supposed to provide information on this. However if they cannot assist with the actual opt-in, call your plan’s customer service number.
  • If you expect high out of pocket costs soon, you can opt-in now – call your Part D plan’s customer service number. Of course, you can opt-in at any time later in 2026, too.
  • Under certain urgent circumstances, you may opt-in to the payment plan retroactive IF:
    • A delay in filling the medication while waiting for the PPP processing would have jeopardized your health, and
    • You contact your Part D plan to opt-in within 72 hours of having picked up and paid for the medication. Be sure to keep the receipt showing the medication, date and payment amount.
  • This may not be the best choice for you if you already receive help paying for drugs through NY EPIC, Extra Help or Medicare Savings Program.
  • You’ll find more information at https://www.medicare.gov/prescription-payment-plan/will-this-help-me
OUT-OF-POCKET LIMIT ON DRUG COSTS

As a reminder, once your Part D drug costs (deductible, co-payments and other credits combined) reach $2,100, your cost for covered Part D medications will be reduced to $0 through December 31, 2026.

Categories
Medicare Part C Medicare Advantage Part D Prescription Drug

What If I Missed the Medicare AEP Deadline?

This year’s Medicare Annual Enrollment Period (October 15 through December 7) was a busy time and we are grateful for the hundreds of individuals and couples who permitted our team of agent advisors to help with their 2026 Part C Medicare Advantage plan selection. (The December 7 deadline does not apply to a Medicare Supplement plan selection.)

Q: But I missed that deadline. Is there another option for me to choose a new plan for 2026?
A: Possibly. Some Medicare participants are eligible for what is called a Special Enrollment Period during which you can make a change to your Medicare Advantage Plan.

Q: Am I eligible for a Special Enrollment Period?
A: Let’s look at some special situations that may apply to you. If one does, you can make changes to your Medicare Advantage plan coverage outside of the normal Annual Enrollment Period:

  • Has your 2025 Medicare Advantage Plan been discontinued? If so, you have some additional time to enroll in new coverage for January 1. One of our agents can assist you with finding a plan that matches your providers, medications and budget.
  • Do you belong to New York State EPIC?  If so, you have one Special Enrollment Period per calendar year to enroll in a new Medicare Advantage or Part D prescription drug plan. [Download the EPIC application here.] 
  • Are you a veteran? Many veterans may not be aware of a valid Special Election Period available by having their prescriptions filled through the Veterans Administration (VA.) Veterans can use that Special Enrollment Period to enroll in a “MA only” plan – a Medicare Advantage plan with no drug benefits.  Click here for more information on MA Only plans.
  • You may be eligible for Social Security Extra Help – Eligibility for this program is based on your income and assets. Extra Help subsidizes part or all of your plan’s premium, drug deductible and reduce prescription co-payment. With Extra Help, you may be able to make changes to your coverage one time during each of these periods:
    • January – March
    • April – June
    • July – September

Q: Do any of these Special Circumstances apply to Medicare Supplement plans?
A: No. However three states, including New York and Massachusetts, do require Medicare Supplement plan insurers to offer policies to Medicare beneficiaries age 65 and older through continuous open enrollment, with guaranteed issue rights  throughout the year.

That means if you want to drop a Medicare Advantage plan (which includes prescription drug coverage) and return to Original Medicare with a Medicare Supplement plan; you need a Special Enrollment Period to add the third piece, your Part D prescription drug coverage.

Q:  I’m not sure of my eligibility status, can you help me with my questions?
A: Yes. Simply use the form below and send a note to an agent advisor or call (518) 346-2115. We’ll discuss your options by telephone or Zoom web conference. And, during your Special Enrollment Period, we may be able to identify a Medicare Advantage, Medigap or Prescription Drug Plan more suited to your needs – even though the December 7 deadline has passed.

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Categories
Medicare A & B

Your 2026 Medicare Part B and D Premiums

May Be Increased. Or Eliminated.

The 2026 standard monthly premium for Medicare Part B beneficiaries is $202.90.

However, your 2026 Medicare Parts B and D premiums could be higher or lower – based on your prior or current income.

  • Higher? Yes. If the Modified Adjusted Gross Income (MAGI) on your 2024 tax filing exceeded $109,000 ($218,000 joint) your 2026 Medicare Parts B and D premiums are increased. This will be withheld from your 2026 Social Security benefit. Here is more information about the Income Related Monthly Adjustment Amount (IRMAA) for Parts B and D
  • Lower? Yes. If your current annual income is below 186% of the Federal Poverty Level you will be eligible for the Medicare Savings QI Program, regardless of assets, and will not be paying any Part B premium.

 

  • If you are being charged IRMAA and had a life-changing event that resulted in a reduction in your income, you may be eligible for a reduction in IRMAA. Call Social Security at 1-800-772-1213 for instructions on how to file an appeal via the SSA-44 form.
  • Plan ahead. Assuming the law is not changed, check with your financial planner or tax preparer to confirm whether your 2025 tax filing will trigger a 2027 IRMAA.
  • Or, if your current monthly income is below $2,426 individual / $3,279 couple one of our agents listed below and we can review whether you are eligible for the Medicare Savings QI Program.

 

Questions?

Our licensed, independent and certified agents are available to answer your questions about Parts A, B, IRMAA and other Medicare topics. Send us a note below to request an individual consultation.

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Categories
Medicare supplement

Why Choose a High Deductible Medicare Supplement Plan?

Medicare Supplement Plan
reason 1:

Lower annual maximum co-pay responsibility ($2,950 in 2026) compared to most Medicare Advantage plans.

reason 2:

Lower annual cost (premium and out-of-pocket) compared to Medicare Supplement Plans F, G or N.

NY STATE RATES APPLICATION
Like with other deductibles, do I pay the first $2,950 in bills?

No. After you pay the Parts A and B deductibles, Medicare pays its share of claims (usually 80%) and you pay the 20%. Once your deductible and 20% share reaches $2,950, then your supplement plan pays 100% for the rest of the year. Think of it as a $2,950 cap on your out of pocket costs.

2026 2025
Part A deductible per period $1,736 $1,676
+ Part B deductible $283 $257
+ Part B co-share 20% 20%
= Maximum Out of Pocket $2,950 $2,870

Will hospitals and doctors will accept my High Deductible plan?

Yes, if your provider participates in Original Medicare for your primary coverage, they will accept your Medigap supplemental coverage; including plans with deductibles like Plans G, N and High Deductible. This way you have access to the nationwide network of doctors and hospitals participating in Original Medicare.

How does a High Deductible compare to Medicare Advantage plan?
      •  Medicare Advantage plans include a limit on out-of-pocket costs; ranging from $6,000 to $9,250 per year for in-network medical services. (Up to $13,900 for in and out of network)  Compare to a Medicare Supplement High Deductible plan with the annual maximum out-of-pocket cost capped at $2,950
      • Medicare Advantage plans manage your Medicare benefits through contracts with in-network providers and hospitals. As mentioned above, any provider accepting Original Medicare for your primary coverage will accept your supplement coverage – eliminating the “is my doctor in-network with my plan” questions.
      • Most Medicare Advantage plans, including those with a low monthly premium, include Part D prescription drug coverage. With Medicare Supplement, you will need to obtain separate creditable Part D drug coverage. during an Annual Enrollment, Open Enrollment or Special Enrollment  Period. VA drug benefits are considered creditable coverage.
      • Many Medicare Advantage plans include features like dental allowance, fitness membership, eyewear and hearing aid benefits not available with Original Medicare.

 Download 3 separate documents↓↓↓
Globe Life application Form 1 sign page 3 (and 5 for EFT)
Globe Life application Form 2 sign page 1
Globe Life application Form 3 sign page 1
About Globe Life Insurance of NY

Our agents are authorized to represent the Globe Life Insurance Company and Humana Medicare Supplement High Deductible Plans. Please call us at (518) 346-2115 or send any agent a quick note with your questions.

Categories
Medicare Medicare A & B Medicare supplement Part C Medicare Advantage Part D Prescription Drug

About the 2026 Medicare Annual Enrollment

Annual Enrollment Period

The Medicare Annual Enrollment Period, from October 15th through December 7th, is when Medicare beneficiaries can enroll in or change their Medicare Advantage (Part C) or Medicare Prescription Drug (Part D) plan to take effect January 1.

Some Important Tips to Consider if you are now enrolled in a Medicare Advantage (Part C) Plan:
  • You can leave your Medicare Advantage plan and enroll in another Medicare Advantage plan offered in your county. [We offer several]
  • Even if you decide to stay with your current Medicare Advantage plan, make sure your doctors and preferred hospitals are still in your network, especially if your plan is a HMO. 
  • You can leave Medicare Advantage and return to Original Medicare and purchase a Medicare Supplement (aka Medigap) policy. For New York State residents, acceptance is guaranteed and the continuous coverage transfer means no pre-existing condition limitations apply.
Some Important Tips to Consider if you HAVE ORIGINAL MEDICARE AND a Medicare SUPPLEMENT Plan:
  • The Annual Enrollment Period applies to your Part D drug plan only.
  • New York State residents can change their Medicare Supplement plan at any time of the year and without medical underwriting. An example could be changing from one company to another or changing from one plan (Plan F, Plan G, Plan N or High Deductible) to another. 
  • You can leave your Medicare Supplement (Medigap) plan and join a Medicare Advantage plan during the Annual Enrollment Period. There is no underwriting to move to a Medicare Advantage plan. You will be automatically accepted as long as your permanent address is within the coverage area.
  • Unless your prescription drugs are covered through the Veterans Administration, most individuals with Original Medicare and a Medicare Supplement plan also add a Medicare Part D prescription drug plan. We recommend updating your medication list and confirming – through your personal account at medicare.gov – which Part D drug plans will cover your prescriptions at the lowest annual out of pocket costs – that includes premium, deductible and prescription copay costs.

Our team of licensed, independent and certified agent advisors, from Long Island to the North Country, offer a no-obligation complimentary consultation to help you compare Medicare plans in your coverage area.

So, reach out to local agent by phone, an online note or book an appointment directly to his or her calendar and learn more about your Medicare plan options.

Categories
Medicare Part C Medicare Advantage Part D Prescription Drug

Medicare Annual Notice of Change

“The ANOCs are in the mail.”
Each year, by September 30, individuals enrolled in a Medicare Advantage (Part C) or Medicare Part D Prescription Drug plan receive by mail a document called Annual Notice of Change (ANOC.)
The ANOC document spells out upcoming changes to the plan you are currently enrolled in and compares those changes to the current year.
Points to Remember:
Your ANOC document is only for the plan you are enrolled in and not any other plan that may be available to you.
The document will confirm that if you take no action during the Annual Enrollment Period, your plan will be renewed January 1 with the new terms.

If your Medicare Advantage or Part D drug plan is being discontinued in 2026, you will receive by October 2 a Notice of Termination instead of the Annual Notice of Change. That plan termination notice must include a list of other plans offered in your county. Our team of licensed and independent agent advisors represent multiple companies and can assist you with selecting a new plan matching your needs.

October 1: This is the first day when we can discuss with you other 2026 plans available in your area. If you have any questions about your ANOC document, our team of licensed, certified and independent agents are available for a complimentary no-obligation review of the announced changes to your Medicare coverage. Click here to locate, call and or send a note to our agent near you.
October 15: This is the day the 2026 Medicare Annual Enrollment Period begins. During this period, which ends on December 7, 2025, you can enroll in or change your Part C Medicare Advantage or Part D Medicare Prescription Drug plan.

Additionally, this is also an important time to protect yourself from fraud and unsolicited behavior.
You may receive phone calls, emails, or mail from individuals offering assistance with your Medicare coverage. Do not allow anyone to pressure you into sharing personal information over the phone, especially your Medicare number, Social Security number, or banking details.
Telemarketing for Medicare Advantage plans without your prior consent is illegal, and Medicare and Social Security will never contact you by phone.

Categories
Medicare A & B Part D Prescription Drug

Changes to the NY Medicare Savings Program in 2025

If you are enrolled in Medicare Parts A and B and have limited income you may be able to get assistance with your health care costs through a Medicare Savings Program (MSP) 

If eligible, you will receive help paying the Medicare Part B premium, (currently $185.00) and automatically get Extra Help, the federal program that helps with prescription drug (Part D) costs such as monthly premium, drug deductible and prescription copays.

The two programs listed below offer separate benefits. You cannot choose which program to apply for – you will be enrolled in the program that corresponds to your income.

New Yorkers previously not eligible for MSP may now qualify effective January 1, 2025.

New 2025 New York Monthly Income Limits (*)
Program Individual Couple
QI (i) Up to $2,426 Up to $3,279
QMB (ii) Up to $1,800 Up to $2,433

(*) Eligibility is based on your income after subtracting for eligible health insurance premium deductions such as i) Medicare Supplement, ii) Part D drug plan, iii) dental, iv) vision, and iv) long term care premiums.

  • (QI) Once enrolled as a Qualified Individual with individual monthly income at or below $2,426 you will no longer have the Medicare Part B premium deducted from your Social Security check.  And you may receive up to three months of retroactive reimbursement for Part B premiums paid before your MSP effective date and within the same year of the effective date.
  • (QMB) If your individual monthly income is at or below $1,800 you would be enrolled in the Qualified Medicare Beneficiary Program and, like QI, will no longer have the Medicare Part B premium deducted from your Social Security check.
    • This program also pays for Medicare Parts A and B deductible and cost sharing however no retroactive Part B reimbursements are available to QMB enrollees.
    • Once enrolled in QMB, consider a Medicare Advantage DUAL (Medicare / Medicaid) plan. On top of the benefits described above, these plans include additional benefits like dental, vision and even an allowance for healthy food. Ask your local agent about the Medicare Advantage DUAL plans we represent for individuals in the QMB program. 

Your local agent can help you with the request. Start by downloading the form below. Then, along with a copy of your Medicare ID card, we’ll need documents to confirm your date of birth, residency and income. If you are paying another health insurance premium, such as i) Medicare Supplement, ii) Part D drug plan, iii) dental, iv) vision, and iv) long term care premiums, we’ll need some proof of that expense. Your local agent will work with you in getting this to your county’s Department of Social Services and follow up with you during the approval process which can takes up to 45 days.

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(i) Qualified Individual income eligibility at 186% of Federal Poverty Level
(ii) Qualified Medicare Beneficiary income eligibility at 138% of Federal Poverty Level
Categories
Part D Prescription Drug

Getting Ready for 2025 Medicare Part D

Passage of the Inflation Reduction Act (2022) has meant several changes to Medicare Part D, including these most frequently mentioned:
  • 2023: Insulin co-pay capped at $35 for 30 day supply.
  • 2024: Catastrophic Coverage Stage cost sharing eliminated.
  • 2025: Annual Out-of-Pocket Drug cost sharing capped at $2000.
  • 2026: Medicare and drug companies, for the first time, will negotiate price on the top ten drugs costing the Part D system the most in taxpayer money.
While millions of Medicare beneficiaries welcome these changes, the federal government is shifting more of the cost of these changes to the Part D drug plan carriers and the pharmaceutical companies. The 2025 drug plans, both standalone Part D and the Medicare Advantage plans including Part D, are published online at medicare.gov Changes to watch for in 2025:
    • Premium changes – with standalone Part D or Medicare Advantage.
    • Drug deductible change – can be as high as $590.
    • Cost sharing change – a prescription which may have previously been quoted a fixed copay may in 2025 be quoted a percentage of the drug cost.
Tips for Getting Ready Now!
   
enroll now in a New York program based on your Income 
Program Individual Couple
1. Medicare Savings < $2,426 mo < $3,279 mo
2. NY EPIC < $75,000 / yr < $100,000 / yr
  1. Medicare Savings Program. If eligible, you will receive help paying the Medicare Part B premium, and automatically get Extra Help, the federal program that helps with prescription drug (Part D) costs such as monthly premium, drug deductible and prescription copays.  Click for more information and MSP Application Form.
  2. For individuals with annual income greater than the above MSP levels, but under $75,000 (up to $100,000 for a couple) the New York State EPIC program is secondary drug coverage – meaning EPIC will, after meeting a deductible, help with your prescription copay.  If you take brand name medications and your 2025 cost sharing is based on percentage of the drug cost, you will want this EPIC secondary coverage in place to start the new year.  (Another benefit to being an EPIC member is having the ability to change your Part D plan one time per year outside of the Annual Enrollment Period.) You can now apply for NY State EPIC online or download, print, complete and mail the EPIC application to their office in Albany:
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3. Questions? Please feel free to contact any of our local, licensed and independent agents using the inquiry form below. We’ve even included a worksheet for you to use when researching which 2025 plans match your medications and providers.
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Categories
Medicare Medicare A & B

Medicare Tips: Part B

Unlike Medicare Part A, which covers inpatient care in a hospital, skilled nursing or hospice facility, Part B covers through outpatient care, services from doctors and other providers, durable medical equipment and many preventative screenings.

  • Individuals already receiving Social Security benefits are automatically enrolled in Parts A and B effective the first day of the month you turn 65.
    • At age 65, individuals choosing to delay their Social Security benefit need to contact Social Security, online or your local office, to activate Parts A and B.
    • Individuals receiving Social Security Disability benefits are automatically enrolled in Parts A and B after 24 months.
    • At age 65, those covered through their individual or spouse’s currently employed group health plan (20 or more employees) may delay Part B WITHOUT PENALTY until they, or their spouse, are no longer employed and the employer coverage ends.
  • The standard Part B premium amount in 2023 is $164.90.
  •  Paying the Part B premium
    • If you receive Social Security benefits, your Part B premium (and the IRMAA adjustment, if applicable) will be deducted from your monthly Social Security payment.
    • If, like me, you are enrolled in Medicare Parts A and B and have deferred the Social Security benefit, Medicare sends a bill (sample below) for the Part B premium and, if applicable, any IRMAA adjustment, which can be paid by check or online.

 

Categories
Medicare Part D Prescription Drug

The New Law and Medicare Part D

Well, just as we are finishing up the annual federal and carrier Medicare Advantage and Part D certifications for 2023, the US House and Senate passed a bill (H.R. 5376 titled Inflation Reduction Act of 2022) which includes some important changes to the Medicare Part D prescription drug coverage.

Some of these changes take effect next year and others over the next several years. I have looked over the text, studied several analysis and have summarized below the 4 changes most likely to Medicare beneficiaries:

  1. Insulin – Effective 2023
  2. Adult Vaccines – Effective 2023
  3. Cap on Out of Pocket Drug Costs – Effective in 2024 and 2025
  4. Medicare to Negotiate Part D and Part B Drug Prices – Effective 2026

Please note: If you are receiving Part D financial assistance through state Medicaid or the Social Security Extra Help program, your benefits may already exceed what is becoming effective in this new bill. Also, if your medications are covered through your VA benefits, you may want to compare these new benefits to what VA covers and compare your options in the years ahead.

1. Insulin – Effective 2023 Beginning in 2023, for Medicare Part D beneficiaries who need insulin, monthly out-of-pocket costs will be capped at $35, and starting in 2026, the cap would be $35 or 25% of the negotiated price if that is lower. And insulin products will no longer subject to a Part D deductible.

2. Adult Vaccines – Effective 2023
Beginning in 2023, Medicare Part D cost-sharing will be eliminated for adult vaccines that are recommended by the Advisory Committee on Immunization Practices. For most clients, the most significant change will be the new $0 Part D copay for the two shot Shingles vaccine, previously covered through Part D however frequently subject to a deductible and higher Tier copay.

3. Cap on Out of Pocket Drug Costs – Effective in 2024 and 2025
For clients with drug costs placing them in the “Coverage Gap” (aka Donut Hole) and Catastrophic Coverage Phase, this change will be very welcomed although phased in over time.

In 2024, that 5% coinsurance payment that now kicks in after someone reaches the catastrophic drug spending level in Medicare will end. As you may imagine, 5% on some of those expensive drugs that cost thousands monthly can be a lot of money. That ends in 2024.

And in 2025 your Medicare Part D out-of-pocket spending will be capped at $2,000 a year.

4. Medicare to Negotiate Part D and Part B Drug Prices
CMS (Centers for Medicare & Medicaid Services) will be authorized and required to negotiate maximum prices for brand-name drugs that do not have other generic equivalents and that account for the greatest Medicare spending.

There is not yet an official, publicly available list of drugs that Medicare plans to target for negotiations. However Kaiser Family Foundation reports how just a handful of drugs represent the lion’s share of Medicare drug costs. Some likely candidates, based on how much Medicare spent on them in 2020: Eliquis, Xarelto and Januvia.

Today, those brand name drugs that do not have generic equivalents and represent the greatest cost are typically listed as Tier 4 or Tier 5 specialty medications under Medicare Part D coverage.

CMS will begin by negotiating the prices of 10 drugs in 2026, 15 drugs in 2027 and 2028, and 20 drugs in 2029 and each year thereafter. The negotiations would apply first to drugs people get at the pharmacy (Part D), but in the later two years, drugs administered in doctors’ offices (Part B) could also be covered.

If you have any questions or would like for me to review with you your plan benefits please schedule a telephone or Zoom conference convenient for you and direct to my calendar, call us at (518) 346-2115 or send a note to one of our licensed and carrier certified agents closest to you:

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