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LANDSCAPE GOING INTO THE 2024 AEP

Inflation Reduction Act

Signed into Law 2022

Baby Boomers 1946 to 1964

Vietnam Veteran Cohort

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Chevron Deference Doctrine Overturned June 28, 2024

Election Year

Data Breaches

LANDSCAPE GOING INTO THE 2024 AEP

Affordable Care Act

enacted in 2010

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NEWS SOURCES TO MONITOR��CMS.GOV NEWSROOM��SSA.GOV NEWSROOM��

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2025 MEDICARE PREMIUMS�AND DEDUCTIBLES��PENDING AS OF 11/8/2024�

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2025 MEDICARE � A,B,C & D�

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PART C – MEDICARE ADVANTAGE PLANS

2025 Medicare Advantage and Part D Star Ratings
Mid-year Ancillary Benefit Notices
Last Minute Benefit Changes
Provider Network Negotiations
Service Area Reductions
Migration to MA from MS
Administrative Cost Increases
Star Rating Pressures
Age-in Claims Rates
Rising Medical Inflation
Suppressing Plans

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2025 MEDICARE PART D �STANDARD DEFINED BENEFIT

A newly defined standard Part D benefit design consisting of three phases:

Annual Deductible Max: $590 (up from $545 in 2024)

Initial Coverage Phase: 25% of their drug costs in the initial coverage phase until their out-of-pocket spending totals $2,000.

Catastrophic Coverage Phase: Will pay no additional out-of-pocket costs.

Note: Coverage Gap Phase (Donut Hole) is completely removed

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INFLATION REDUCTION ACT

Max out of pocket for Medicare Part D - $2000

Starting in 2025, all Medicare plans will include a $2,000 cap on what you pay out-of-pocket for prescription drugs covered by your plan. If your out-of-pocket spending on covered drugs reaches $2,000 (including certain payments made on your behalf, like through the Extra Help program), you’ll automatically get “catastrophic coverage.” That means you won’t have to pay out-of-pocket for covered Part D drugs for the rest of the calendar year.

All prescription medications covered by Part D plans are included under this cap, including deductibles, copayments, and coinsurance for covered drugs.

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Reaching the $2000 TrOOP in 2025

You will get credit toward their out-of-pocket Part D drug spending (TrOOP) for the “greater of” either:

What the person actually spends through their Enhanced Alternative plan's cost-sharing or

The cost-sharing for the same formulary drug purchase as if they were enrolled in a Defined Standard drug plan with the standard 25% cost-sharing and a $590 deductible.

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MEDICARE PRESCRIPTION PAYMENT PLAN (MPPP)�

The Inflation Reduction Act that requires Part D plan sponsors to provide their enrollees with the option to pay out-of-pocket prescription drug costs in the form of monthly payments over the course of the plan year instead of all at once to the pharmacy.

The program begins on January 1, 2025. Program participants will pay $0 to the pharmacy for covered Part D drugs, and Part D plan sponsors will then bill program participants monthly for any cost sharing they incur while in the program. Pharmacies will be paid in full by the Part D sponsor in accordance with Part D prompt payment requirements.

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MEDICARE PRESCRIPTION PAYMENT PLAN (MPPP)�

During Medicare Open Enrollment, Medicare Part D enrollees will be able to opt into the Medicare Prescription Payment Plan for the 2025 plan year. Part D enrollees will also have the opportunity to opt in throughout the year.

Managed by insurance carriers. Part D sponsors will be responsible for correctly calculating the monthly caps based on the statutory formulas, determining the amount to be billed (up to the cap), and sending monthly bills to their enrollees who have opted into the program.

The fluctuating monthly payment amounts can be very difficult to understand or predict for Medicare beneficiaries.

Resource: https://www.cms.gov/inflation-reduction-act-and-medicare/part-d-improvements/medicare-prescription-payment-plan

Medicare Prescription Drug Payment Program Examples

https://www.medicare.gov/prescription-payment-plan/examples

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2025 MEDICARE SUPPLEMENTS�

Many carriers are adjusting their rate to accommodate for the losses they are currently experiencing.

Medicare Supplements work with original Medicare thus they pay claims based on a fee-for-service schedule. Therefore, they are limited to their ability to control utilization and loss ratios.

Medicare Supplements are state regulated, and many states have added legislation that limits any ability to underwrite their enrollments.

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KEY DATES

Initial Enrollment Period

Generally, when you turn 65. This is called your Initial Enrollment Period. It lasts for 7 months, starting 3 months before you turn 65, and ending 3 months after the month you turn 65.

Annual Enrollment Period

October 15-December 7

Open Enrollment Period (only if you’re already in a Medicare Advantage Plan)

January 1-March 31.

Within the first 3 months you get Medicare

Service Area Reduction

Between December 8 and the last day in February of the following year.

Special Enrollment Period

There are certain situations when you can sign up for Part B (and premium-Part A) without paying a late enrollment penalty. Medicare Advantage and Prescription Drug plans can also have special enrollment periods for special circumstances.

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Refreshers

Medicare Advantage - Medicare Publication: 12026

https://www.medicare.gov/publications/12026-understanding-medicare-advantage-plans.pdf

Medicare Supplement - Medicare Publication: 02110

https://www.medicare.gov/publications/02110-medigap-guide-health-insurance.pdf

Medicaid – CMS.gov MLN006977

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/mln-publications-items/cms1244469

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SPECIFIC �CLIENT CIRCUMSTANCES

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VIETNAM VETERANS

During the 1960s to 1973, U.S. combat troops were deployed in Vietnam. The youngest possible Vietnam War Era vets turn 69 this year.

Very few are actually this young; almost all these Vets are in their 70s and 80s.

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CHRONIC CONDITIONS��DISABILITY��MEDICAID/LOW INCOME��GROUP INSURANCE

Specific Client Circumstances

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HIGH INCOME

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HSA ACCOUNT HOLDER

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CAREGIVER��More than 50 million Americans provide crucial care and medical assistance to parents, children, siblings and other loved ones.��HTTPS://WWW.CMS.GOV/TRAINING-EDUCATION/PARTNER-OUTREACH-RESOURCES/PARTNER-WITH-CMS/CAREGIVER-PARTNERS�

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2026 AND BEYOND�

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SOME HIGH-PRICED DRUGS WILL BE CHEAPER

In 2026, the first year that drug pricing will be up for negotiation, the list will include the 10 drugs that Medicare spent the most money on the prior year. By 2029, that list expands to 20 drugs

Source: https://www.cms.gov/newsroom/fact-sheets/medicare-drug-price-negotiation-program-negotiated-prices-initial-price-applicability-year-2026

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REFERENCE MATERIAL�

State Specific Information Fact Sheets

https://www.cms.gov/files/document/2025-ma-part-d-landscape-state-state-fact-sheet.pdf

CMS Planning Tools

Nearing 65: Google CMS Product # 11961

Over 65 and Retiring: Google CMS Product # 11963

Introduction to Medicare: Google CMS Product # 11960

Cost/Eligibility Calculator – Medicare.gov search “Estimate cost”

Mail You Get From Medicare - https://www.medicare.gov/basics/forms-publications-mailings/mailings

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