Obamacare Program Update for Plan Year 2026 – Change is Coming!

 

Background

The Obamacare health care reform law, formally known as the Affordable Care Act (ACA), was created in 2010 by the federal government to extend health insurance coverage and reduce the financial burden of medical expenses for millions of uninsured adults. ACA plans were first issued effective January 1, 2014; and the enrollment process that started the prior October through the Health Insurance Marketplace was chaotic that first year, if it worked at all.

Obamacare expanded Medicaid services, created federal and state Marketplaces (currently about 20 states operate their own state-based enrollment platforms), prevented denial of medical coverage due to pre-existing conditions, and required plans to cover 10 Essential Health Benefits (EHBs) with a cap on maximum out-of-pocket expenses. Two types of federal subsidies were introduced based on projected household income and size: the Advance Premium Tax Credit (APTC), or monthly premium subsidy, and Cost Sharing Reductions (CSRs), which make plans more affordable by lowering the amount eligible enrollees must pay for deductibles and other out-of-pocket costs. CSRs apply only to applicants up to 250% of the Federal Poverty Level (FPL) enrolling into a Silver-level ACA plan.

Initially, the ACA faced legal challenges, and the program’s popularity was divided along political party lines. The ACA prevailed at the U.S. Supreme Court, which struck down the argument that the ACA was unconstitutional. However, Medicaid expansion was left up to the states.

Perhaps the most unpopular aspect of the ACA was a tax ‘penalty’ imposed on anyone without an exemption from the mandate to be covered by a health care plan (an ACA plan, commercial group health, Medicare, or other qualifying coverage). In late 2017, President Trump signed a tax bill zeroing out the tax penalty for coverage issued in 2018 and thereafter.

With the ACA tax penalty gone, Obamacare gained popularity across both political parties, despite some national insurers exiting (but later re-entering) sales of ACA plans. Democrats remained the main proponents, and then on March 11, 2021, Obamacare was given a major overhaul when President Biden signed the sweeping “American Rescue Plan Act” into law.

The American Rescue Plan created temporary enhanced subsidies that later were extended through the end of 2025 by the Inflation Reduction Act (signed by President Biden in 2022). Higher-income people over 400% FPL could receive a subsidy for the first time; plus, the subsidy amount was increased for lower-income people already eligible. Further, maximal subsidies were given to those who received unemployment benefits (for 2021), and the law forgave individuals from having to repay excess ACA premium subsidies at tax time (for 2020). Finally, subsidized COBRA coverage was made available for laid-off workers (from April to September of 2021), and the 14 states that had not yet expanded Medicaid were given new financial incentives to do so.

Higher income individuals and families went from being ineligible for any federal premium subsidy to potentially qualifying for substantially reduced premium (possibly half, or even less, of the total plan premium). The applicable threshold is if benchmark premiums exceed 8.5% of household income.

Under the American Rescue Plan, individuals and families under 400% FPL (already eligible for PTCs) gained access to higher subsidies. Notably, those with incomes between 100%-150% of the Federal Poverty Level could qualify for zero-premium coverage when electing a Silver-level benchmark plan (under prior law, they had to contribute premium up to approximately 2% of income).

ACA Provisions Set to Sunset on 12/31/2025

The enhanced premium subsidies detailed above are set to expire on 12/31/2025; and without an unforeseen extension, subsidized ACA coverage is about to become a lot more expensive. As noted, individuals and families projecting over 400% FPL will lose subsidy eligibility entirely.

A recent report published by the Center on Budget and Policy Priorities estimated that a family of four making $85,000 would pay an additional $313 in monthly premiums for coverage in 2026, as well as face a $900 increase in their cap on total out-of-pocket medical expenses.

For reference, the 2025 Federal Poverty Level guidelines (applicable for 2026 ACA plans) are shown below (figures are for the 48 contiguous states).

2025 FPL:

Family Size of 1: $15,650

Family Size of 2: $21,150

Family Size of 3: $26,650

Family Size of 4: $32,150

For example, a family of four projecting $140,000 total annual household income in 2026 is at the 435% FPL level, rendering them ineligible for any premium subsidy next year. Currently, if this family were enrolled in my home zip code, they would be eligible for a monthly premium subsidy of $554 ($6,648 for the full calendar year). So, absent any change in the current landscape, this family is facing an increase of more than $6,600 in total 2026 premiums – not including premium rate increases due to yearly inflation that are extremely likely to be implemented.

ACA Program “Pause” of Year-Round Enrollment SEP

In 2021, the U.S. Department of Health and Human Services (HHS) finalized a new special enrollment period (SEP) in states that use HealthCare.gov (optional for states that operate a state-based exchange), granting Year-Round enrollment in ACA plans for household income up to 150% FPL. That Year-Round enrollment provision was extended through 2025 under the 2022 Inflation Reduction Act and became permanent under a rule change HHS made in 2024.

Under this SEP, eligible applicants can enroll in an ACA plan through the Marketplace at any time during the year. Coverage takes effect on the first of the following month (this is true even in state-run exchanges as of 2025; prior to 2025, state-run exchanges could set mid-month enrollment deadlines for coverage to take effect the first of the following month).

In states that have expanded Medicaid, due to the very narrow range between 138% of the current year’s FPL (for Medicaid eligibility) and 150% of the prior year’s FPL, a small segment of the population is helped by this year-round enrollment SEP. In states not expanding Medicaid, more people are impacted (those qualifying for a federal subsidy and within 100%-150% FPL).

So, is this special Year-Round enrollment period truly permanent? No, of course not!

The Trump administration’s “Marketplace Integrity and Affordability” rule (effective August 25, 2025, for some provisions, and for other provisions, Plan Year 2026 or Plan Year 2027) has paused the Year-Round SEP for ACA enrollees at or below 150% FPL. HHS clarified the low-income SEP will once again be available, at the option of each exchange, for Plan Year 2027.

The rationale for this HHS rule is that the low-income SEP played a significant role in allowing fraudulent enrollments, and that it is potentially resulting in adverse selection, with people waiting until they need medical services to enroll in coverage.

Other ACA Program Changes

A host of other changes are approaching:

Deferred Action for Childhood Arrivals (DACA) recipients lose eligibility for coverage because of the Marketplace Integrity and Affordability rule. HHS estimates that 10,000 DACA recipients will lose Marketplace coverage, and 1,000 people will lose Basic Health Program (BHP) coverage. While DACA recipients became eligible for Marketplace coverage in November 2024, access to enroll in Marketplace plans was soon revoked in 19 states that sued to prevent DACA recipients from enrolling (DACA recipients in the rest of the country have continued to be eligible, but that will end in August 2025).

While the Marketplace currently requires income verification for some applications with income mismatches or missing IRS data, we should expect all Marketplace applicants to be required to provide proof of household income when attesting to household income that does not match information the exchange gets from its trusted data sources (such as the applicant's most recent year’s tax return).

The final rule also permanently removes the current automatic 60-day extension to the regular 90-day window that applicants are given to provide requested income documentation.

Like the low-income SEP rule change, the income verification change is temporary and applies only through the end of 2026.

Another change is directed towards ACA enrollees who take advantage of grace period provisions and, for example, look for ways to ‘skip’ a premium payment. Under the new rules, ACA plan enrollees who owe past-due premium to an insurer and apply for a new policy with that insurer must pay the past-due premium to effectuate the new policy (unless contrary to state laws and regulations). If the applicant does not remit the past-due premium, the insurer will be allowed to refuse to effectuate the new policy.

A technical change has been made, impacting maximum out-of-pocket limits. Starting in 2026, the new rule finalizes a methodology change for how maximum out-of-pocket limits are calculated, and the result is that the highest allowable out-of-pocket limit for a single individual will be $10,600 in 2026. Under the previous methodology, the Biden administration had finalized a 2026 maximum out-of-pocket limit of $10,150, but that has now been replaced.

The impact on ACA plan enrollees will be higher out-of-pocket costs and less generous premium subsidies. Since the IRS uses the same premium indexing methodology to determine the percentage of income that Marketplace enrollees pay in after-subsidy premiums, the new methodology will also have the effect of reducing premium subsidies (this is because it will increase the percentage of income that people pay in after-subsidy premiums).

A new administrative rule will impact enrollees in $0 (after-subsidy) premium plans who let their plans auto-renew in 2026. Auto-renewal of ACA plans is widely used, as evidenced by the enrollment period for 2025 coverage, in which more than half of the approximately 20 million people who renewed Marketplace coverage utilized auto-renewal. 

Under the new rules, if ACA enrollees with a 2025 $0 premium plan rely on auto-renewal for their 2026 coverage, they cannot be approved for $0 premium coverage until they reconfirm basic eligibility information in their Health Insurance Marketplace account. Until doing so, these enrollees will incur a minimum of $5 premium due each month.

Like some of the rules noted above, the auto-renewal change is temporary and applies only for the 2026 Plan Year (and it does not apply to state-run exchanges).

But wait, that’s not all! The budget bill enacted on July 4, 2025 (known as the One Big Beautiful Bill Act) calls for Marketplace auto-renewal to end altogether, starting with the 2028 Plan Year. Marketplace enrollees will have to verify their ongoing eligibility for coverage to ensure receipt of premium subsidies each year (Marketplaces will have the option to rely on automatic verification protocols for confirming information, when available from trusted data sources).

The final rule permanently removes “Bronze-to-Silver” auto-renewal, a protocol that Healthcare.gov adopted in 2024, allowing the Marketplace to switch a consumer from a Bronze plan to a Silver plan in some circumstances. Under this process, if an applicant is eligible for CSRs, enrolled in a Bronze plan, and a Silver plan is available in the same product category with the same provider network, and with equal or lesser after-subsidy premiums, the exchange can auto-renew the enrollee into the Silver plan (allowing the enrollee to take advantage of CSRs).

The final rule prohibits this protocol, starting with the 2026 Plan Year. Instead, the auto-renewal will keep the enrollee in their existing plan if it continues to be available. State-run exchanges can retain flexibility regarding their re-enrollment protocols, but only at the discretion of HHS.

Pre-enrollment SEP eligibility verification will be stricter for the 2026 Plan Year. In recent years, HealthCare.gov applicants enrolling under a SEP have only been required to provide proof of their SEP eligibility if the qualifying life event was the loss of other qualifying coverage. The final rule removes that limitation, allowing pre-enrollment verification for any qualifying life event.

The exchange will be required to conduct pre-enrollment SEP eligibility verification for at least 75% of new SEP enrollments. Originally, the proposed rule called for this to apply nationwide, but it was only finalized for states that use HealthCare.gov (state-run exchanges will continue to have the option to verify applicants’ SEP eligibility or not).

A shorter open enrollment period is on the way, but not until Plan Year 2027. HHS had initially proposed a shorter open enrollment period starting in the fall of 2025, but the final rule pushes this out until the fall of 2026. So, the open enrollment period for Plan Year 2026 is slated to begin on November 1, 2025, and continue through January 15, 2026, in most states. State-run exchanges will have the option to extend it even later than that, which several have historically done.

But starting in the fall of 2026, and for future years, open enrollment will be shorter:

In states that using healthcare.gov, it will run from November 1 to December 15.

State-run exchanges will have the option to extend open enrollment, but only within certain parameters:

• It must begin no later than November 1
• It can’t continue past December 31
• It can’t last longer than nine weeks.
• All policies selected during open enrollment will take effect January 1

The open enrollment period will continue to apply both “on-exchange” and “off-exchange” (ACA-compliant health insurance, without availability of federal subsidies, sold outside of the Marketplaces). 

Already this year, at least one large national insurer has decided to fold its hand and exit the Health Insurance Marketplaces for Plan Year 2026. CVS Health, owner of Aetna, recently announced that Aetna will withdraw all ACA individual and family plans at the end of 2025 (Aetna has cited persistent underperformance in its ACA exchange business, including substantial financial losses).

This isn’t Aetna’s first time pulling back from sales of ACA plans. After exiting in 2018 and coming back in 2022, the company is shifting gears once again. While it’s not possible to know for sure, it would seem Aetna is keenly interested in its profit margin, more so than serving the American public.

As an editorial comment, people who earn too much to receive federal subsidies have seen individual market health insurance premiums rise steeply, in some cases ten-fold, compared to a dozen years ago. That’s in addition to the continuing trend of higher deductibles, out-of-pocket caps, etc. Proponents of Obamacare tout the value of APTCs, CSRs, coverage of pre-existing conditions, children allowed on their parents’ plan until age 26, and other components of the program, which clearly have helped many people… but at what overall cost?  Administrative and regulatory burdens under Obamacare are enormous, and arguably those expenses would be much better directed toward actual medical care.

To conclude, I shall share a remark posted last month on a popular financial website by a commenter who is unknown to me, but apparently has more common sense than many of our government leaders: 

The Bronze Plan is complete rubbish. 60/40, high deductible, covers nothing really, unless you are hit by a bus. Let's put Congress on the Bronze Plan. They have a Mercedes Benz Plan right now. Time for them to feel the pain of the average citizen. That should cut some 'government waste.' 

Until next time,

 

Andrew Herman, President

AH Insurance Services, Inc.

 

 

 

 

 

 

Medicare Advantage Trial Periods – What Are They and How Do They Help Medicare Beneficiaries?

Over half of current Medicare Beneficiaries receive benefits through Medicare Part C, an alternative to the Original Medicare program.  Under Medicare Part C, Beneficiaries enroll in health and drug plans offered by private insurance companies contracted with the federal government to provide Medicare benefits on a year-to-year basis.  Part C plans (known as Medicare Advantage) are governed by enrollment period rules that dictate when initial sign-up, plan changes, and disenrollments can be made.

Medicare Advantage plans sometimes are confused with Medicare Supplement policies widely available to Medicare Beneficiaries.  Medicare Supplement also is known as Medigap, as it serves to fill in gaps in medical benefits under the Original Medicare program design.  Beneficiaries on Original Medicare (with or without Medigap) optionally can obtain drug coverage via a Standalone Medicare Part D Prescription Drug Plan.  Federal rules govern enrollment timeframes for Medicare Part D, like Medicare Advantage.

A major difference between Medicare Advantage and Medigap is that in most locations, Medicare Advantage plans with rich benefits often come with a $0 plan premium (i.e., no additional premium beyond the Medicare Part B monthly premium), unlike Medicare Supplement policies that always have a monthly premium (and for those choosing to add a Standalone Medicare Part D plan, that premium is in addition).

With Medicare Advantage including Part D benefits and many extras not covered by Medicare such as dental, vision, hearing, fitness benefits, transportation to the doctor, over-the-counter allowances, and sometimes an allowance for food and utilities, it can be surprising to learn that so many plans have a $0 premium.  Some Medicare Advantage plans even refund a portion of the Medicare Part B premium to the Beneficiary.  Finally, there is no medical underwriting and pre-existing medical conditions are covered.  This has led some people to conclude that “Medicare Advantage must be too good to be true.”

For those who are skeptical (often people who already have Medigap or plan to buy it at Age 65), there is some good news, namely, Medicare Beneficiaries are provided special protection to try out Medicare Advantage on a trial basis.  There are two Federal Trial Periods, both of which provide Guaranteed Issue Rights to buy a Medigap policy if dissatisfied with Medicare Advantage during the first year.

These trial rights are meaningful, as Medigap applicants generally face medical underwriting once the open enrollment period (six months following sign-up for Medicare Part B) has ended.  Medigap underwriting assesses medical history and can impose higher premiums or deny coverage completely.

State laws, such as in Maine and Wisconsin, provide additional protection for Medicare Beneficiaries wishing to try Medicare Advantage for the first time.  These rights are described below following the Federal Trial Periods.

Medicare Advantage Trial Periods: Returning to Original Medicare

Medicare Advantage trial periods are types of Special Enrollment Periods (SEPs) that allow Medicare Beneficiaries to disenroll from a Medicare Advantage plan outside of the Annual Election Period (AEP) that runs each year from October 15th to December 7th (disenrollments during AEP normally take effect the first day of the following year).  If disenrolling from a Medicare Advantage plan that includes prescription drug coverage, a SEP is granted to enroll in a Standalone Medicare Part D drug plan.

Along with allowing disenrollment from Medicare Advantage outside of standard election periods, the Federal Trial Periods grant Guaranteed Issue Rights for the Beneficiary to purchase a Medigap policy.  The government currently specifies two distinct SEPs for this purpose.

I.  Medicare Advantage Special Enrollment Period at Age 65 – “SEP 65” (Federal Trial Period)

The “SEP 65” is for Beneficiaries who enrolled in a Medicare Advantage plan for the first time at Age 65 during their Medicare Initial Enrollment Period (IEP).  Those who qualify can disenroll from Medicare Advantage and return to Original Medicare within the first 12 months of coverage.  If the Medicare Advantage plan included Part D coverage, a Part D SEP may be used to enroll in a Standalone Part D plan.  Medicare Advantage disenrollment takes effect on the 1st of the month following receipt of the request by the plan.  Beneficiaries using this SEP 65 have a Guaranteed Issue Right to purchase any Medigap plan available to them, regardless of their current health status or any adverse medical history.  This means insurers cannot deny coverage or increase premiums based upon medical history.  Medigap coverage must be purchased within 63 days after leaving Medicare Advantage (Beneficiaries also can purchase the Medigap plan starting 60 days before Medicare Advantage coverage ends).

II.   Medicare Advantage Special Enrollment Period – “Trial Period SEP” (Federal Trial Period)

The “Trial Period SEP” allows Beneficiaries of any age enrolling in a Medicare Advantage plan for the first time when dropping a Medigap policy, the right to disenroll from Medicare Advantage and return to Original Medicare within the first 12 months of coverage.  If the Medicare Advantage plan included drug coverage, a Part D SEP may be used to enroll in a Standalone Part D plan.  Medicare Advantage disenrollment takes effect on the 1st of the month following receipt of the request by the plan.  Beneficiaries using this Trial Period SEP have a Guaranteed Issue Right to purchase their prior Medigap plan, regardless of current health status or medical history.  If the prior plan is no longer available for sale, any available Medigap Plan A, B, C, D, F, G, K, or L may be selected (except that Plans C and F are available only to Medicare Beneficiaries who turned age 65 or became first eligible for Medicare because of age, disability or end-stage renal sickness prior to January 1, 2020).

III.  Maine “State Trial Period” (specific to Maine, extends period to three years)

Maine mandates that Beneficiaries who enroll in Medicare Advantage starting at the same time as initial enrollment into Medicare Part B and then switch back to Original Medicare within three years, are given a Guaranteed Issue Right to buy any available Medicare Supplement plan during the 90-day period after Medicare Advantage coverage ends.  Without this Guaranteed Issue right, Beneficiaries must health-qualify for Medigap coverage once their Medicare Part B has been effective for more than six months.

While Maine’s Trial Period SEP provides additional rights to buy Medigap without health underwriting, it does not change Federal rules that allow a return to the Original Medicare program only at certain times.

Additionally, Maine mandates that Beneficiaries with an existing Medicare Supplement policy who terminate that plan to enroll in Medicare Advantage for the first time, and then return to the Original Medicare program within three years, use their Guaranteed Issue Right to buy an equivalent or less comprehensive Medicare Supplement policy available to them (Beneficiaries must apply within 90 days).

IV.  Wisconsin “State Trial Period” (Guaranteed Issue Right – Dropping Employer Coverage)

Wisconsin offers yet another protection for Medicare Beneficiaries.  If a Beneficiary drops an employer-sponsored group health plan to enroll in a Medicare Advantage plan for the first time, the Beneficiary is given a Guaranteed Issue Right to purchase a Medicare Supplement policy when the Beneficiary disenrolls from Medicare Advantage during the first 12 months (this is the Wisconsin Trial Period right).  To disenroll from Medicare Advantage, Beneficiaries must follow Federal enrollment period rules to switch back to Original Medicare and optionally enroll in a Standalone Part D plan.

Summary

The Federal government has two Trial Periods for Medicare Beneficiaries wishing to try a Medicare Advantage plan for the first time without losing eligibility for Guaranteed Issue Medigap coverage.  Beneficiaries can use a Trial Period once, for up to one year, to determine if a Medicare Advantage plan is suitable.  Maine has adopted rules extending the one-year trial period to three years, and Wisconsin grants Medicare Beneficiaries an additional Guaranteed Issue Right to buy a Medigap plan when terminating an employer-sponsored group health plan to enroll in Medicare Advantage for the first time.

Until next time,

 

Andrew Herman
President of AH Insurance Services, Inc.

Medicare 2025 - New Premiums and Deductibles, Changes to Part D Program

 CMS Updates Medicare Premiums, Deductibles, and Coinsurance Amounts

Last month, the Centers for Medicare & Medicaid Services (CMS) released 2025 premiums, deductibles and coinsurance amounts for the Medicare Part A and Part B programs, and the new 2025 Medicare Part D income-related monthly adjustment amounts.

Part A (Hospital Insurance) Monthly Premium

About 99% of Medicare beneficiaries do not pay a monthly Part A premium (it is required that the Medicare beneficiary or a spouse has 40+ quarters of Medicare-covered employment).

The 2025 Part A premium is $518 per month for people who are not otherwise eligible for premium-free Hospital Insurance and have less than 30 quarters of Medicare-covered employment.  With 30-39 quarters of Medicare-covered employment, the 2025 Part A premium is $285 per month.  Higher income consumers may pay more.

Part B (Medical Insurance) Monthly Premium

Medicare Part B covers physician services, outpatient hospital services, certain home health services, durable medical equipment, and certain other medical and health services not covered by Medicare Part A.  General tax revenues, along with premiums paid by Medicare beneficiaries, fund the Part B program.

There is a special rule for Social Security recipients, called the “hold harmless rule,” ensuring that Social Security benefits will not decline from one year to the next because of an increase in the Medicare Part B premium.  Whether this rule comes into play in any year depends on the amount of Cost of Living Adjustment (COLA) and the Medicare Part B premium increase.  Medicare beneficiaries who have been protected by the hold harmless rule pay less than the standard Part B premium.  All others pay monthly 2025 Part B premiums based on the Modified Adjusted Gross Income (MAGI) as reported two years prior (i.e., 2023 federal tax return).

The standard 2025 monthly premium for Medicare Part B enrollees is $185.00, an increase of $10.30 from $174.70 in 2024.  Medicare Part B enrollees will pay the standard $185.00 Part B premium amount in 2025 unless:

• You have Medicare and Medicaid, and Medicaid pays your premiums.  (Your state will pay the standard premium amount.)
• Your modified adjusted gross income as reported on your IRS tax return from two years ago is above a certain amount.  If so, you’ll pay the standard premium amount plus an Income Related Monthly Adjustment Amount (IRMAA).
• You have been protected by the "hold harmless" rule discussed above.

Since 2007, a beneficiary’s Part B monthly premium is based on income.  These income-related monthly adjustment amounts affect approximately 8% of people with Medicare Part B.  2025 Part B premiums for Full Part B coverage (as opposed to Part B Immunosuppressive Drug Coverage only) based on MAGI from the 2023 tax return are shown in the following table:

Beneficiaries who file individual tax returns with income:	Beneficiaries who file joint tax returns with income:	2025 Part B premium not held harmless	Premium level
Less than or equal to $106,000	Less than or equal to $212,000	$185.00	Standard
Greater than $106,000 and less than or equal to $133,000	Greater than $212,000 and less than or equal to $266,000	$259.00	1.4 x standard
Greater than $133,000 and less than or equal to $167,000	Greater than $266,000 and less than or equal to $334,000	$370.00	2.0 x standard
Greater than $167,000 and less than or equal to $200,000	Greater than $334,000 and less than or equal to $400,000	$480.90	2.6 x standard
Greater than $200,000 and less than $500,000	Greater than $400,000 and less than $750,000	$591.90	3.2 x standard
Greater than or equal to $500,000	Greater than or equal to $750,000	$628.90	3.4 x standard

For tables for married beneficiaries who file separate returns, and for Part B Immunosuppressive Drug Coverage only, click here:  https://ahinsuranceservices.com/medicarepremiums.html.

Part D (Prescription Drug Coverage) Monthly Premium

Since 2011, Medicare beneficiaries’ Part D premiums have been based on income.  In addition to any Part D plan premium, there is an income-related monthly adjustment amount (IRMAA) impacting higher income earners.  Part D plan premiums vary from plan to plan (when Part D benefits are included in a Part C Medicare Advantage plan, premiums often are zero).  Beneficiaries may pay Part D premiums directly to the plan or have them deducted from Social Security benefits; however, any IRMAA must be deducted from Social Security benefits or otherwise paid directly to Medicare.  2025 Part D IRMAA figures are shown in the following table: 

Beneficiaries who file individual tax returns with income:	Beneficiaries who file joint tax returns with income:	2025 Part D base premium*	IRMAA
Less than or equal to $106,000	Less than or equal to $212,000	Plan premium	$0
Greater than $106,000 and less than or equal to $133,000	Greater than $212,000 and less than or equal to $266,000	Plan premium	$13.70
Greater than $133,000 and less than or equal to $167,000	Greater than $266,000 and less than or equal to $334,000	Plan premium	$35.30
Greater than $167,000 and less than or equal to $200,000	Greater than $334,000 and less than or equal to $400,000	Plan premium	$57.00
Greater than $200,000 and less than $500,000	Greater than $400,000 and less than $750,000	Plan premium	$78.60
Greater than or equal to $500,000	Greater than or equal to $750,000	Plan premium	$85.80

For married beneficiaries who file separately, click here:

https://ahinsuranceservices.com/medicarepremiums.html.

Part A (Hospital Insurance) Deductible and Coinsurance Amounts

In 2025, the Medicare Part A inpatient hospital deductible that beneficiaries pay if admitted to the hospital will be $1,676, an increase of $44 from $1,632 in 2024.  The Part A inpatient hospital deductible covers beneficiaries’ share of costs for the first 60 days of Medicare-covered inpatient hospital care in a benefit period.  In 2025, beneficiaries must pay a coinsurance amount of $419 per day for the 61st through 90th day of a hospitalization ($408 in 2024) in a benefit period and $838 per day for lifetime reserve days ($816 in 2024).  For beneficiaries in skilled nursing facilities, the daily coinsurance for days 21 through 100 of extended care services in a benefit period will be $209.50 in 2025 ($204.00 in 2024).

Part B (Medical Insurance) Deductible

The annual deductible for all Medicare Part B beneficiaries will be $257 in 2025, an increase of $17 from the annual deductible of $240 in 2024.

2025 Changes to Medicare Part D (Prescription Drug Coverage)

Medicare Part D coverage, whether on a Stand-alone basis or included within a Part C Medicare Advantage plan, can include a yearly deductible up to $590 in 2025.  This is an increase of $45 from $545 in 2024.  Many Part D plans that have a deductible apply it only to higher cost prescriptions such as those classified in Drug Tier 3 and higher.

Notable Part D Program changes coming in 2025 are as follows:

The Coverage Gap (also known as the "Donut Hole") will be completely eliminated.

Under the original Part D program, Part D enrollees faced up to 100% of total drug costs during a Coverage Gap stage.  Years later, the 100% amount was reduced to 25%.  In 2025, Part D enrollees will no longer face any increase in cost sharing due to hitting the cost threshold that would trigger the dreaded Donut Hole, as it has been eliminated.

Part D enrollees' out-of-pocket drug costs will be capped at $2,000 in 2025.  This amount will be indexed to rise each year at the rate of growth in per capita Part D costs (this cap does not apply to out-of-pocket spending on prescription drugs covered under Medicare Part B).

You might spend even less if you are one of the roughly 75% of Part D members with an “enhanced” Part D plan, which may provide extra credit toward the out-of-pocket cap.  When enhanced plans have benefits that reduce out-of-pocket spending, the value of those benefits can count toward your $2,000 cap.)  As a result, many Medicare beneficiaries will hit the cap before actually spending $2,000 in out-of-pocket costs.

It is important to keep in mind that only medicines listed in your plan's Part D formulary count toward the $2,000 out-of-pocket cap.  There may be certain exceptions, such as when a plan agrees to cover a non-formulary drug due to individual circumstances (this typically requires the prescribing physician to document medical need). 

Part D plans and drug manufacturers will pay a larger share of costs for Catastrophic Coverage beyond the $2,000 cap, and Medicare will pay a smaller share.  Medicare's share of total costs will decrease from 80% to 20% for brand-name drugs and from 80% to 40% for generic drugs beginning in 2025.  Medicare Part D plans' share of costs will increase from 15% to 60% for both brands and generics above the cap, and drug manufacturers will be required to provide a 20% price discount on brand-name drugs.

Part D plans and manufacturers will face changes to their share of total drug costs paid in the Initial Coverage stage.  In this stage (i.e. after any plan deductible has been met and before Catastrophic coverage), drug manufacturers will be required to provide a 10% discount on brand-name drugs (this replaces the 70% discount in the Coverage Gap stage under the current design).  Part D plans will pay 65% of brand-name drug costs.

One additional change coming in 2025 is the Medicare Prescription Payment Plan, which is a new, optional way to pay out-of-pocket costs over time.  It works like a “buy now, pay later option” for Medicare Part D deductibles, copays and/or coinsurance.

The payment plan is a potential budgeting tool, not something that will save you money.  Total costs remain the same, and plans cannot charge fees or interest because you participate.  The Medicare Prescription Payment Plan could be helpful if you have expensive medications and incur high out-of-pocket costs early in the year, for example. 

All 2025 Medicare Part D plans will offer the Medicare Prescription Payment Plan, and plans will be required to reach out to you if they identify you as likely to benefit from the program.  Enrollment in this optional program is done through your Part D plan.

Until next time,

Andrew Herman

Medicare Part D Enrollees to Benefit from Program Changes in 2024 and 2025

With nearly two decades having passed since Medicare Part D became operational, notable program improvements are on the horizon for 2024 and 2025.

For background, Medicare Part D is prescription drug coverage available to Medicare Beneficiaries enrolled in Part A and/or Part B.  Beneficiaries access this voluntary program through private insurance carriers and can obtain coverage through a standalone Prescription Drug Plan (PDP) or a Medicare Advantage Prescription Drug (MA-PD) plan (must have both Medicare Parts A and B to enroll in MA-PD).

Medicare Part D plans run on a calendar year basis (subject to change each year) in distinct stages:

• Deductible – enrollees are responsible for a plan deductible up to a maximum ($505 in calendar year 2023).  Some PDPs do not have any deductible (this feature may come with a higher plan premium).

• Initial Coverage – after the Deductible is reached, enrollees have a copay ($) or coinsurance (%) based on each drug’s “Tier Level” as shown in the plan formulary.  The standard Part D design allows plans to charge up to 25% coinsurance, but actual costs will vary and often are lower.  Medicines must be on the plan formulary, or they will not be covered at all (unless an exception applies).  This stage continues until the consumer’s out-of-pocket costs PLUS the amount the plan pays reaches $4,660 (in 2023).

• Coverage Gap (“Donut Hole”) – in this stage, under the original standard design of the Part D program, enrollees bore the full cost of their medicines.  Prior to 2023, the program was gradually liberalized so that in this stage, enrollees pay only 25% of drug costs (with the remainder covered by manufacturer discounts).  During each year, enrollees exit the Donut Hole once their True Out-of-Pocket (TrOOP) costs reach a threshold level ($7,400 in 2023).  It should be noted that TrOOP includes what the manufacturers pay, in addition to costs paid by the enrollee (it does not include what the plan pays during Initial Coverage).

• Catastrophic Coverage – the final stage in a calendar year once an enrollee has hit the Part D TrOOP.  In this stage, in calendar year 2023, enrollees pay the greater of 5% of drug costs, or $4.15 for generics and $10.35 for brand names.  For very costly medicines, the 5% enrollee portion can add up quickly.

To illustrate actual 2023 out-of-pocket drug costs on a standalone PDP, let's review a hypothetical example for a Medicare beneficiary living in Tampa, Florida and taking one costly medicine -- Pomalyst 3mg capsule.  Then, we will see how much the enrollee's out-of-pocket costs will be reduced in 2024 and 2025.

The monthly premium is ignored, but it should be noted that the Plan Sponsor selected in this example provides the lowest standalone Part D 2023 calendar year costs including premiums and drug copays.

According to the Medicare plan finder, this consumer travels through both Initial Coverage and the Coverage Gap in January.  The $7,400 TrOOP is reached, with the enrollee’s out-of-pocket drug cost equal to $3,080.  For the rest of the year, the enrollee is in Catastrophic Coverage paying $1,188 monthly (5% of $23,762 pharmacy retail cost).  Over the whole calendar year, the enrollee’s out-of-pocket drug costs exceed $16,000 (based on the specific 2023 PDP and retail pharmacy).

So, what will change in 2024 and how will this enrollee be impacted?

In 2024, costs in the Catastrophic stage change so that the 5% coinsurance requirement is eliminated (Part D plans will pay 20% of total drug costs in this phase instead of 15%).  Once Part D enrollees (without low-income subsidies, called LIS), have drug spending high enough to qualify for Catastrophic Coverage, they are no longer required to pay 5% of their drug costs, which in effect caps their expenses.

In 2024, the Catastrophic stage threshold will be set at $8,000.  As noted above, this amount includes what Part D enrollees spend out of pocket plus the value of manufacturer discounts in the Coverage Gap.  Under this construct, Part D enrollees who take only brand-name drugs in 2024 will spend approximately $3,300 out of pocket and then have no further cost for covered medicines.  So, in the example cited, the enrollee reduces out-of-pocket medicine costs from over $16,000 in 2023 to about $3,300 in 2024.

So, what is changing in 2025 and how will this enrollee be further impacted?

Out-of-pocket drug spending will be capped at $2,000.

Beginning in 2025, Part D enrollees’ out-of-pocket drug costs will be capped at $2,000.  This amount will be indexed to rise each year after 2025 at the rate of growth in per capita Part D costs.  (This cap does not apply to out-of-pocket spending on prescription drugs covered under Medicare Part B.)

For Part D enrollees who take only brand name drugs, annual out-of-pocket costs at the Catastrophic threshold will fall from around $3,300 in 2024 to $2,000 in 2025.  In other words, Part D enrollees who take only brand name drugs with costs high enough to reach the Catastrophic stage should expect to realize savings of about $1,300 in 2025 as compared to 2024 spending.

The Coverage Gap will be completely eliminated.

The Coverage Gap stage, where Part D enrollees had faced 100% of total drug costs under the original Part D design and currently face 25% of costs, will be eliminated in 2025.  This means that Part D enrollees will no longer face an increase in cost sharing at the end of the Initial Coverage stage, which is the case in most Part D plans, since today's plans usually vary the cost-sharing amounts instead of charging the standard 25% coinsurance during Initial Coverage.

Part D plans and drug manufacturers will pay a larger share of costs for Catastrophic Coverage, and Medicare will pay a smaller share.

Medicare’s share of total costs in the Catastrophic stage (reinsurance) will decrease from 80% to 20% for brand-name drugs and from 80% to 40% for generic drugs beginning in 2025.  This reduction will help address concerns about the substantial increase in Medicare’s reinsurance payments to Part D plans over time, which accounted for close to half (48%) of total Part D spending in 2022, up from 14% in 2006, based on data from the Medicare Trustees 2023 annual report.  Medicare Part D plans’ share of costs will increase from 15% to 60% for both brands and generics above the cap, and drug manufacturers will be required to provide a 20% price discount on brand-name drugs.

Part D plans and manufacturers will face changes to their share of total drug costs paid in the Initial Coverage stage.

Drug manufacturers will be required to provide a 10% discount on brand-name drugs in the Initial Coverage state beginning in 2025, replacing the 70% price discount in the Coverage Gap stage under the current design.  Part D plans will pay 65% of brand-name drug costs.

For further information and graphics that illustrate upcoming Part D changes in greater detail, please refer to this informative article from the Kaiser Family Foundation:

https://www.kff.org/medicare/issue-brief/changes-to-medicare-part-d-in-2024-and-2025-under-the-inflation-reduction-act-and-how-enrollees-will-benefit/.

Until next time,

Andrew Herman

Highlights of the 2023 Medicare Trustees Report

The 2023 Medicare Trustees Report spelled good news for the program’s short-term viability but should not delay Congress from seeking a long-term solution that protects the health care of older Americans, experts agreed.

As part of a webinar this month sponsored by the American Academy of Actuaries, the Centers for Medicare & Medicaid Services’ (CMS) Chief Actuary Paul Spitalnik reported on the program’s finances as detailed in the report.  Three other panelists shared insights on how Medicare’s Hospital Insurance trust fund might remain solvent beyond the currently projected exhaustion date, and more generally how to make the program more sustainable in the long-term.

For background, the Medicare Program consists of multiple parts:

Part A - Covers inpatient hospital and skilled nursing care, post-institutional home health care, and hospice care.

Part A has about 65 million enrollees and is funded primarily by Medicare payroll taxes (1.45% paid by employees and employers, each; 2.90% paid by self-employed; additional .90% paid by high-income earners; and no cap on annual taxable earnings as is the case with the Social Security payroll tax).  Calendar year 2022 expenditures were $342.7 billion.

Part B - Covers physician services, outpatient hospital, diagnostic testing, durable medical equipment, ambulance, some additional services such as general home health care, and physician-administered drugs.

Part B has about 60 million enrollees and is funded approximately 30% by monthly premiums paid by Medicare beneficiaries ($164.90 standard premium for 2023 plus additional premiums charged to high-income earners) and 70% by government contributions coming from general taxation.  A small portion of revenue stems from fees imposed on drug manufacturers.  Calendar year 2022 expenditures were $436.7 billion.

Part D - Covers prescription drugs.

Part D has slightly over 50 million enrollees and is funded by premiums paid by Medicare beneficiaries (average monthly premium is about $32, funding about 15% of total revenues), additional premiums charged to high-income earners, general federal revenues, and state transfers.  Calendar year 2022 expenditures were $125.7 billion.

Part C - Medicare Advantage program.

The Part C (Medicare Advantage) program is an option for Medicare beneficiaries that are enrolled in both Part A and Part B and live in the service area where the private plan of choice is offered.  These plans are provided on a calendar-year basis by plan sponsors contracted with Medicare.  Medicare Advantage plans, which typically include Part D coverage, now cover close to half of Medicare beneficiaries nationwide.

The Medicare program has grown dramatically in both enrollment and paid benefits over the past four decades.  In 1982, Medicare benefits totaled $46.6 billion, or 1.4% of the nation’s gross domestic product (GDP).  The 2023 report found that had grown to $911.2 billion overall, or 3.6% of GDP.

Key highlights of the 2023 Medicare Trustees report are as follows:

The Part A Hospital Insurance trust fund (a long term reserve that has been set aside to cover future costs) is projected to be depleted by the year 2031, three years later than forecast in last year's report.  This is great news for the program's short-term viability, yet the eventual financial shortfall will need to be addressed to avoid reduction in program benefits.

The Inflation Reduction Act of 2022, intended to tamp down inflation and reduce the federal budget deficit, will impact Medicare in several ways:

• Reduces government expenditures for physician and outpatient services covered under Part B

• Increases expenditures for Part D through 2030

• Decreases Part D expenditures beginning in 2031

In the long-term, experts expect the Inflation Reduction Act of 2022 will be beneficial to the financial health of the Medicare program.

While the COVID-19 pandemic caused higher costs for acute treatment, those costs have been more than offset by deaths of seriously ill Medicare beneficiaries as well as reduced spending for non-COVID care.

The growing number of members portends long-term challenges.  James Mathews, executive director of the Medicare Payment Advisory Commission (MedPAC), noted that the number of program beneficiaries is expected to increase from the current 65 million to 80 million in the next decade.  At the same time, the number of workers supporting those on Medicare is projected to decrease from 4 per enrollee to 2.5 per enrollee.

To control costs, MedPAC is advising cuts to post-acute care payments in 2024 as well as reducing Medicare Advantage plan payments in excess of payments made to Original Medicare.  MedPAC also continues to advocate for reductions in Part D plans’ reliance on cost-based reinsurance and improved incentives to manage benefits.  However, Mathews said a hike in hospital payment rates is necessary to cover rising hospital costs.

Marilyn Serafini, executive director of the Bipartisan Policy Center’s Health Program, said it is essential that Congress seek out a bipartisan solution that will keep Medicare fully functioning.  Her group is currently in the midst of crafting recommendations to improve the program in the long-term.

It is developing a set of principles to guide policymakers, including improving the enrollment process, simplifying and improving the traditional Medicare benefit, promoting price competition in both Original Medicare and Medicare Advantage, and re-evaluating the trust fund structure and accountability mechanisms.

It is extremely likely additional funds will be needed to support growing Medicare enrollment.  Bowen Garrett, senior health fellow at the Urban Institute, noted that Congress in the past has always acted when the program neared fund exhaustion—as is happening now.  That’s for good reason, as doing nothing “would be a significant stressor on providers.”

The Urban Institute has examined 12 different options to raise revenues, ranging from an across-the-board increase in payroll or income taxes, to taxing health care benefits, or targeting solutions that would only impact more wealthy Americans or businesses.

Regardless of the path taken, there was broad agreement for congressional action in the near future to save Medicare for future generations.  “Demographics are pretty clear,” CMS Chief Actuary Spitalnic said.  “It is a question of when it will be depleted.”

Until next time,

Andrew Herman, President

AH Insurance Services, Inc.

2023 Medicare – New Expanded Enrollment Access, Update to Premiums and Deductibles, and New Immunosuppressive Drug Benefit

CMS Updates Medicare Enrollment and Eligibility Rules

On October 28, 2022, the Centers for Medicare & Medicaid Services (CMS) issued a final rule effective on January 1, 2023, updating Medicare enrollment and eligibility rules to expand coverage for people with Medicare and advance health equity.  Among the changes, Medicare coverage now becomes effective the month after enrollment for individuals signing up in the last three months of their Initial Election Period, or in the General Election Period, thereby reducing potential gaps in coverage.

The rule also expands access through Medicare special enrollment periods (SEPs) and allows eligible beneficiaries to receive Medicare Part B coverage without a late enrollment penalty.  Examples of new SEPs created by this rule are SEPs for eligible individuals who miss an enrollment opportunity because:

1. They were impacted by a disaster or government-declared emergency;
2. Their employer or health plan materially misrepresented information related to timely enrollment in Medicare Part B;
3. They were incarcerated; and
4. Their Medicaid coverage was terminated after the COVID-19 Public Health Emergency (PHE)s ends or on or after January 1, 2023 (whichever is earlier).

These changes are related to Original Medicare A/B eligibility only.  They do not apply to Medicare Advantage.  The effective dates and SEPs for Medicare Advantage remain unchanged.

The final rule also establishes a new immunosuppressive drug benefit that extends vital Medicare immunosuppressive drug coverage to individuals who have had a kidney transplant and otherwise would lose Medicare coverage.

To view the final rule, refer to this link:

https://www.federalregister.gov/documents/2022/11/03/2022-23407/medicare-program-implementing-certain-provisions-of-the-consolidated-appropriations-act-2021-and.

2023 Medicare Part A Premium, Deductible, and Coinsurance Amounts

Medicare Part A covers inpatient hospital, skilled nursing facility, and some home health care services.  About 99 percent of Medicare beneficiaries qualify for premium-free Part A due to having at least 40 quarters of their own Medicare-covered employment (or the work history of a spouse), or two years having passed from initial eligibility for Social Security Disability benefits.

Enrollees aged 65 and over who have fewer than 40 quarters of coverage and certain persons with disabilities must pay premium for Medicare Part A.  Individuals who had at least 30 quarters of coverage or were married to someone with at least 30 quarters of coverage may buy into Part A at a reduced monthly premium rate of $278 in 2023 (increase of $4 from 2022).  Certain uninsured aged individuals who have less than 30 quarters of coverage and certain individuals with disabilities who have exhausted other entitlement will pay the full premium of $506 a month in 2023 (up $7 from 2022).

The Medicare Part A inpatient hospital deductible that beneficiaries pay if admitted to the hospital is $1,600 in 2023 (increase of $44 from 2022).  The Part A inpatient hospital deductible covers beneficiaries’ share of costs for the first 60 days of Medicare-covered inpatient hospital care in a benefit period.  In 2023, beneficiaries must pay a coinsurance amount of $400 per day for the 61^st through 90^th day of a hospitalization (increase of $11 from 2022) in a benefit period and $800 per day for lifetime reserve days (increase of $22 from 2022).  For skilled nursing facilities, the daily coinsurance for days 21 through 100 of extended care services in a benefit period is $200.00 in 2023 (up $5.50 from 2022).

2023 Medicare Part B Premium and Deductible Amounts

Medicare Part B covers physician services, outpatient hospital services, certain home health services, durable medical equipment, and certain other medical and health services not covered by Medicare Part A.  General tax revenues, along with premiums paid by Medicare beneficiaries, fund the Part B program.

There is a special rule for Social Security recipients, called the “hold harmless rule,” that ensures that Social Security benefits will not decline from one year to the next because of an increase in the Medicare Part B premium.  Whether this rule comes into play in any year depends on the amount of Cost of Living Adjustment (COLA) and the Medicare Part B premium increase.  The hold harmless rule applies in 2023 for those people who had been paying the standard Part B premium, and their Medicare Part B premium increased but the Social Security COLA amount was not large enough to cover the increase.  Those who are subject to the 2023 hold harmless rule pay less than the $164.90 standard Part B premium.  All others pay the 2023 not held harmless premium, which is determined based on the Modified Adjusted Gross Income (MAGI) as reported on the individual’s 2021 tax return.

The standard monthly premium for Medicare Part B enrollees is $164.90 for 2023, a decrease of $5.20 from $170.10 in 2022.  In most years (unlike 2023), the Medicare Part B premium rises.  Medicare Part B enrollees will pay the standard $164.90 Part B premium amount in 2023 unless:

• You have Medicare and Medicaid, and Medicaid pays your premiums.  (Your state will pay the standard premium amount.)
• Your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount.  If so, you’ll pay the standard premium amount and an Income Related Monthly Adjustment Amount (IRMAA).  IRMAA is an extra charge added to your premium.
• You are protected by the "hold harmless" rule discussed above.

Since 2007, a beneficiary’s Part B monthly premium is based on his or her income.  These income-related monthly adjustment amounts affect less than 10 percent of people with Medicare Part B.  The 2023 Part B premiums based on MAGI from the 2021 tax return are shown in the following table:

Beneficiaries who file individual tax returns with income:	Beneficiaries who file joint tax returns with income:	2023 Part B premium not held harmless	Premium level
Less than or equal to $97,000	Less than or equal to $194,000	$164.90	Standard
Greater than $97,000 and less than or equal to $123,000	Greater than $194,000 and less than or equal to $246,000	$230.80	1.4 x standard
Greater than $123,000 and less than or equal to $153,000	Greater than $246,000 and less than or equal to $306,000	$329.70	2.0 x standard
Greater than $153,000 and less than or equal to $183,000	Greater than $306,000 and less than or equal to $366,000	$428.60	2.6 x standard
Greater than $183,000 and less than $500,000	Greater than $366,000 and less than $750,000	$527.50	3.2 x standard
Greater than or equal to $500,000	Greater than or equal to $750,000	$560.50	3.4 x standard

Medicare Part B has an annual deductible of $226 in 2023 (down $7 from 2022), then Medicare beneficiaries are responsible for 20% of the Medicare-approved amount for services.

2023 Medicare Part D Premiums

Since 2011, Medicare beneficiaries’ Part D premiums have been based on income.  In addition to any Part D plan premium, there is an income-related monthly adjustment amount (IRMAA) impacting less than 10% percent of people with Medicare Part D.  Part D premiums vary from plan to plan (note when Part D benefits are included in a Part C Medicare Advantage plan, there may not be any premium).  Roughly two-thirds of beneficiaries pay premiums directly to the plan, while the remaining beneficiaries have their premiums deducted from their Social Security benefit checks.  Regardless of how a beneficiary pays their Part D premium, the Part D income-related monthly adjustment amounts are deducted from Social Security benefit checks or paid directly to Medicare.  The 2023 Part D income-related monthly adjustment amounts for high-income beneficiaries are shown in the following table: 

Beneficiaries who file individual tax returns with income:	Beneficiaries who file joint tax returns with income:	2023 Part D base premium*	IRMAA
Less than or equal to $97,000	Less than or equal to $194,000	Plan premium	$0
Greater than $97,000 and less than or equal to $123,000	Greater than $194,000 and less than or equal to $246,000	Plan premium	$12.20
Greater than $123,000 and less than or equal to $153,000	Greater than $246,000 and less than or equal to $306,000	Plan premium	$31.50
Greater than $153,000 and less than or equal to $183,000	Greater than $306,000 and less than or equal to $366,000	Plan premium	$50.70
Greater than $183,000 and less than $500,000	Greater than $366,000 and less than $750,000	Plan premium	$70.00
Greater than or equal to $500,000	Greater than or equal to $750,000	Plan premium	$76.40

 * Hold harmless rule does not apply to Medicare Part D premiums for prescription drugs.

New for 2023 -- Immunosuppressive drug benefit

If you only have Medicare because of End Stage Renal Disease (ESRD), your Medicare coverage, including immunosuppressive drug coverage, ends 36 months after a successful kidney transplant. Medicare offers a benefit that helps you pay for your immunosuppressive drugs if you don't have certain types of other health coverage (like a group health plan, TRICARE, or Medicaid that covers immunosuppressive drugs).  This new benefit only covers your immunosuppressive drugs and no other items or services.  It isn’t a substitute for full health coverage.  You can sign up for this benefit anytime as long as you had Medicare because of ESRD at the time of your kidney transplant.  To sign up, call Social Security at 1-800-772-1213.  TTY users can call 1-800-325-0788.

Note:  You’ll pay a monthly premium of $97.10 (or higher based on your income) and $226 deductible for this benefit in 2023.  Once you've met the deductible, you'll pay 20% of the Medicare-approved amount for immunosuppressive drugs.  If you have limited income and resources, you may be able to get help from your state to pay for this benefit.

Until next time,

Andrew Herman