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Community Medicare supplement Part C Medicare Advantage

Will Lyons joins our team!

Alcorn & Associates is pleased to welcome William Lyons of Wynantskill to our Eastern New York team of licensed health insurance agents.

With more than 10 years of experience helping people navigate Medicare, Will has had the opportunity to assist hundreds of Medicare beneficiaries throughout the greater Capital Region, including Schoharie, Montgomery, Fulton, Rensselaer, Albany, Schenectady, Saratoga, Columbia, and Greene counties, as well as communities throughout Upstate New York. His Medicare career includes sales and leadership roles with CDPHP and Fidelis Care/Wellcare. Will enjoys taking the time to explain Medicare in simple, easy-to-understand terms and helping each person find coverage that fits their individual needs.

Will has been preparing for the 2027 Medicare Annual Enrollment Period by researching, contracting and completing required certification with six Medicare Advantage / Medicare Supplement companies serving Upstate New York. We look forward to Will joining our team of agents in continuing to serve the local community and helping Medicare beneficiaries feel confident in their healthcare decisions.

You can reach Will at (838) 295-8160 or send him a quick note using our online inquiry form below:

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Categories
Medicare Medicare A & B

Medicare & You 2027

Each September, Medicare beneficiaries receive by mail the official US government Medicare handbook for the upcoming year.

A Medicare beneficiary should read the official Medicare & You 2027 handbook to navigate significant shifts in out-of-pocket costs, prescription drug rules, and benefit flexibilities taking effect for the 2027 plan year.

For example… Prescription Drug Cost Caps: The handbook, on pages 85 and 87, outlines the updated Part D annual out-of-pocket prescription drug spending cap, which rises to $2,400 for 2027, alongside details on how to use the ongoing Medicare Prescription Payment Plan to spread costs over the year.

New Coverage and Care Options: Page 92 includes details on newly expanded access criteria for specific weight-management medications (like GLP-1 drugs)

IRMAA: Medicare uses the modified adjusted gross income reported on your IRS tax return from 2 years ago to determine if you’ll pay an extra charge, called the Income-Related Monthly Adjustment Amount (IRMAA). For 2027, if your modified adjusted gross income for 2025 was above $111,000 if you file individually or $222,000 if you’re married and file jointly, then you may pay an IRMAA. Check out page 86 for more details.

Section 11 is County Specific: This is where you will find listings of Part C Medicare Advantage and Part D Prescription Drug Plans offered in your county. for 2027.

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Questions? Reach out to one of our independent licensed agents for assistance at (518) 346-2115 or by sending a note below:

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Medicare Part C Medicare Advantage Part D Prescription Drug

Medicare Annual Notice of Change for 2027

Each September, individuals currently enrolled in a Medicare Advantage (Part C) or Medicare Part D Prescription Drug plan will 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.

Important Points:

  • The ANOC will be mailed by the insurance plan and should arrive by September 30th. Please do not discard this as junk mail. We advise you to read this carefully and make note of any premium, benefit and/or cost changes planned for the upcoming year.
  • Your ANOC document is specific for the plan you are enrolled in. If your spouse is enrolled in a different plan, their notice will be different.
  • The document will state that if you take no action during the Annual Enrollment Period, your plan will automatically be renewed January 1 with the new terms.
  • If your Medicare Advantage or Part D drug plan is being discontinued in 2027, 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.

What the ANOC Does Not Include:

  • The ANOC does not include a list of Medicare Advantage plan’s network of providers and facilities. We advise you double check with your agent to confirm that your current providers will remain “in-network” with the specific plan name.
  • The ANOC is not a substitute for the Medicare Advantage or Part D prescription drug plan’s formulary of covered medications and tier levels. We advise you double check with your agent to confirm whether your current medications will be included in the plan’s formulary for the next years and, if so, the medication’s assigned tier level.
  • The ANOC does not provide information on any other plan that may be available to you. All of the plans available in your county are published online at medicare.gov

The Calendar:

October 1: This is the first day when we can discuss with you other 2027 plans available in your area.
October 15 – December 7: This is the 2027 Medicare Annual Enrollment Period. During this period, you can enroll in or change your Part C Medicare Advantage or Part D Medicare Prescription Drug plan.

Questions? Our team of local, licensed and independent agents are available to assist. Just send a quick note and s/he will be gald to get back to you.

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Categories
Part C Medicare Advantage

What is Medicare Advantage?

  • Medicare Part C is also known as Medicare Advantage (MA)
  • MA plans are approved by Medicare and run by private insurance companies as an alternative to Original Medicare.
  • CMS (Medicare) pays these private insurers to manage your Medicare Parts A and B benefits and pay your claims on behalf of CMS.
  • MA plans must have the same or better benefits than Original Medicare.
  • Some plans may include additional supplemental benefits such as dental, eyewear, fitness and wellness coverage that go beyond what what Original Medicare offers. These additional benefits vary so please refer to the plan’s Summary of Benefits for details.
  • Many MA plans also include Part D prescription drug benefits. These are MAPD plans.
  • All MA plans contract with a network of providers, hospitals and vendors. Generally, your copay and cost sharing responsibility is lower when using an “in-network” provider when compared to one not contracted with your plan.
Categories
Part C Medicare Advantage

About Those Nursing Home Denials and Appeals

Earlier this month, Wall Street Journal published an article about a federal investigation(i) update into Medicare Advantage insurers’ rejection rates for patients seeking nursing home stays.  

The OIG review found that only 13% of prior authorization denials issued by Medicare Advantage organizations actually met federal Medicare coverage rules. Stays in post-acute facilities were highlighted as one of the most prominent service types improperly denied, meaning these vital nursing home and rehab stays likely would have been approved under traditional, government-run Medicare. (Medicare typically covers a nursing-home stay if patients need skilled care after a hospital admission of three days or more.)

The investigation noted that most people don’t appeal when the Medicare Advantage insurer denied their doctor’s request for access to a skilled nursing facility.  There is likely a number of reasons why that is the case; people give up, arrange for alternative care, pay out of pocket or simply don’t realize the initial denial is not the final word. 

However, of the 18% of patients who did appeal, nearly all of them were able to overturn the initial denial. 

Prior Authorization and Appeals

Medicare Advantage plans are when a private company, not the federal government, is managing and coordinating your Medicare Parts A and B benefits. Since these plans were introduced in 1999, and modified in 2003 to include drug coverage, the presumption has been these private companies can do a better job at improving health outcomes while saving the taxpayers money. 

In doing so, the private insurance company managing your benefits has the right to request “prior authorization” of a service provided by a Medicare participating provider or facility. The insurance company must post a list of services that require prior authorization and make a decision within seven days. Beginning in 2027 the companies must publish the percentage of PA requests approved vs. denied as well as the average and median time it took to make the decision.

An individual enrolled in a Medicare Advantage plan, or the physician requesting the service, can appeal; the formal way to ask the company to change the coverage decision. 

In Short..

Medicare Advantage plan insurance companies are under intense pressure from the federal government (and in some cases, corporate shareholders) to reduce cost while improving health outcomes. That means more scrutiny (another term for managed care) and prior authorization requirements. Physician groups now employ an army of people whose only job is to appeal the Medicare Advantage insurance company authorization denials. If individuals, too, join the appeal the reporting shows the denials can be overturned.   

(i)Health and Human Services Office of Inspector General (OIG)

Categories
Part C Medicare Advantage Part D Prescription Drug

About the Medicare GLP-1 Bridge Program

Beginning July 1, 2026, a new federal initiative called the Medicare GLP-1 Bridge Program will allow individuals enrolled in a Part D plan to access certain highly sought-after weight-loss drugs for a flat copay of $50 a month.

According to the Centers for Medicare & Medicaid Services (CMS), this temporary demonstration program will run through December 31, 2027. The goal is to make these treatments more affordable while the government evaluates long-term coverage models.

Here are the essential details you need to know about who qualifies, what is covered, and how to get started.

1. Who Is Eligible?

You must be enrolled in a standalone Medicare Part D prescription drug plan or a Medicare Advantage plan that includes drug coverage. (This excludes the MA-Only plans that do not include drug coverage.) However, because this is a medical demonstration, you cannot simply request the $50 rate at the pharmacy counter. Your doctor must submit a Prior Authorization showing you meet specific medical categories based on your Body Mass Index (BMI):

  • Tier 1: A BMI of 35 or higher (no other health conditions required).

  • Tier 2: A BMI of 30 to 34.9 plus at least one of these conditions: heart failure, uncontrolled high blood pressure, or chronic kidney disease.

  • Tier 3: A BMI of 27 to 29.9 plus at least one of these conditions: pre-diabetes, a history of a heart attack, a history of a stroke, or peripheral artery disease.

Note: The program specifically excludes patients who have Type 2 diabetes, moderate-to-severe sleep apnea, or fatty liver disease, as those individuals are typically already eligible for GLP-1 coverage directly through standard Part D plans.

2. Which Medications Are Included?

The $50 monthly price is the result of a negotiated agreement between the federal government and certain drug manufacturers. The program strictly covers specific brand-name formulations prescribed specifically for weight management:

  • Wegovy® (both the standard injectable and the newer oral tablet versions).

  • Zepbound® (strictly limited to the KwikPen® formulation; standard single-dose vials or pens are not covered).

  • Foundayo® (Eli Lilly’s newly approved oral pill).

Medications like Ozempic® and Mounjaro® are not part of this $50 weight-loss program because they are FDA-approved to treat Type 2 diabetes and are already handled under standard Medicare Part D formularies.

3. The “Fine Print” Seniors Need to Know

Because the Bridge program operates entirely outside of the traditional Medicare Part D design, there are a few unique rules to keep in mind:

  • Out-of-Pocket Limits: The $50 monthly copay does not count toward your standard Part D deductible or your annual $2,100 out-of-pocket maximum.

  • Extra Help: Because the program includes a flat $50 copay for everyone who qualifies, the federal Low Income Subsidy (Extra Help) and New York State EPIC cost-sharing protections do not apply to this program.

  • Supply Limits: The program will only cover 28-day or 30-day supplies at a time.

How to Take Action

You do not need to sign up for a new insurance plan to participate. If you think you meet the BMI and health criteria, schedule an appointment with your doctor. Your physician will need to write the prescription with specific instructions for the Bridge program, and they will submit the required medical paperwork directly to the program’s central processor (managed by Humana) to approve your $50 rate. You may want to provide your provider with a copy of the CMS Prescriber Guide and the CMS Pharmacy Operational Framework. for their review.

Click below and watch our June 9 “Ask the Experts” interview where Chris, Kate and I answer some questions about the GLP-1 Bridge Program:

An interesting article comparing several GLP-1 medications: https://www.health.com/glp-1s-weight-loss-8674445

 

Categories
Medicare A & B Part D Prescription Drug

Changes to the NY Medicare Savings Program in 2026

If you are enrolled in Medicare Parts A and B and have limited income you may be able to get assistance with your Medicare health care costs through a Medicare Savings Program (MSP) administered through each state’s Medicaid office: https://www.health.ny.gov/health_care/medicaid/program/update/savingsprogram/

If eligible, you will receive help paying the Medicare Part B premium, (currently $202.90) and are automatically enrolled in Extra Help, the federal program that helps with Medicare prescription drug (Part D) costs such as monthly premium, drug deductible and prescription copays.

The Medicare Savings Program has two eligibility levels – with additional benefits available to those with the lower income. You do not choose which program to apply for – you will be enrolled in the level program that corresponds to your income.

2026 New York Monthly Income Limits (*)
Program Individual Couple
QI Up to $2,494 Up to $3,375
QMB Up to $1,856 Up to $2,509

(*) 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. The Part B premium ($202.90) or any IRMAA surcharges deducted from your Social Security award cannot be used to lower your income. 

  • (QI) Once enrolled as a Qualified Individual with individual monthly income at or below $2,474 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 $1,856 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.
  • FYI: If your individual monthly income is at or below $1,856 and your assets are below $33,308 you may apply separately for Full Medicaid you may enjoy the same benefits as QI and QMB plus some additional benefits such as:
    • County based transportation to and from medical appointments.
    • Dental and vision allowances approved by NY State Medicaid

Once approved at the QMB or Full Medicaid level, you may want to consider a Medicare Advantage DUAL (Medicare / Medicaid) plan. On top of the benefits described above, these plans include additional benefits like dental, vision, fitness membership and even an allowance for healthy food. Ask your local agent about the Medicare Advantage DUAL plans we offer for individuals enrolled in QMB or Full Medicaid.

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, you will need to provide 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.

>> To download application form: click here

Include the following verification documents with your Medicare Savings Program application:

  • A photocopy of the front and back of your Medicare card(s) (red, white and blue card).
  • Proof of Date of Birth, such as State Driver’s license, U.S. Birth Certificate, U.S. passport, Permanent Resident Card (“Green Card”), or NYS Benefit Identification Card.
  • Proof of Residence, such as lease/ letter/ rent receipt with your home address from landlord, utility bill (gas, electric, phone, cable, fuel or water), property tax records or mortgage statement. These documents must be dated within 6 months of when you signed the application.
  • Proof of income, such as paycheck stubs (4 weeks), a letter from employer, pension information indicating amount and frequency of payment, income tax return, award letter for any unearned income benefit such as Social Security, unemployment, or veteran’s benefit, or letter from renter, boarder or tenant.
  • Proof of any other health insurance premium that you pay other than Medicare, such as Medicare Supplement, Medicare Advantage, Part D prescription drug, dental, vision or long term care policy.
  • If you are not a U. S. citizen, you must provide documents indicating your current immigration status such as I-551 Permanent Resident Card (“Green Card”), I-766 Employment Authorization Card.  

Check with New York State Department of Health for an online listing of each county’s Local Department of Social Services:     https://www.health.ny.gov/health_care/medicaid/ldss.htm

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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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