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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 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 scores of individuals and couples who permitted our team of agent advisors to help with their 2021 Part C Medicare Advantage or Part D Prescription drug plan selection. (The December 7 deadline did 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 2021?
A: Possibly. Some Medicare participants are eligible for what is called a Special Enrollment Period during which you can make a change to your Part D prescription drug or Medicare Advantage Plan. This is separate from the October 15 – December 7 Annual Enrollment Period.

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

  • 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.) Vets 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.
  • In New York State the State Pharmaceutical Assistance Program (*) known as EPIC can help with a portion of your drug plan’s premium and reduce prescription co-payments. EPIC members also have one Special Enrollment Period per calendar year to enroll in a new Medicare Advantage or Part D prescription drug plan. [Download the 2020 EPIC application here.] 
  • Social Security Extra Help – Eligibility for this program is based on your income and assets. Extra Help subsidizes part or all of your drug plan’s premium and deductible and reduce prescription co-payments. 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 (New York, Massachusetts and Connecticut) 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, web conference or an in person visit. 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.

(*) In Massachusetts, the SPAP is Prescription Advantage.
(*) In New Jersey, the SPAP is PAAD and Senior Gold

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Categories
Case Studies Part D Prescription Drug

“Thank you again for giving me my life back.”

…. it’s great to hear results.

Just before Thanksgiving I met with a recently widowed woman who was reeling from her loss and struggling to make sense of her health plan costs and dramatically reduced monthly income.

When she disclosed her assets and monthly income, I explained to her some programs she was likely eligible for and provided assistance with the enrollment process.

For starters, the easy one. I enrolled this client in the New York State Elderly Pharmaceutical Insurance Coverage (EPIC) program. EPIC helps with Medicare Part D premiums, prescriptions co-pays and the Part D “donut hole.”

Then, we confirmed she was eligible for Social Security Extra Help – available to Medicare participants with limited resources.

Third, New York State offers Part B premium assistance to Medicare participants with limited income and resources.

I love what I do.

When I received this note with the closing “Thank you again for giving me my life back” it reminds me of why we serve – to add some value to another’s life.  This is fulfilling and rewarding in its own way.

2016 0215 Thank you note