Medicare Changes & Marketplace Tips

 

Medicare Changes & Marketplace Tips

For Release Nov. 5, 2024

 

PODCAST OPEN:      

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MUSIC BRIDGE

 

Stacy Courtnay:

Welcome to the Live Yes! With Arthritis podcast. My name is Stacy Courtnay. I am a volunteer from Atlanta. I’ve had rheumatoid arthritis for about 20 years. And I am excited to be here today as your host as we discuss this very important topic, which is open enrollment and Medicare changes.

 

Open enrollment is in full swing for Medicaid and Medicare plans, as well as for the health insurance marketplace. We have Alisa and Nick joining us today to explain open enrollment and talk about some important changes that people on Medicare need to know. So, Alisa, welcome. Thank you for joining us. Tell us a little bit about yourself.

 

Alisa Casavant:

Thanks, Stacy. It's great to be on. My name's Alisa Casavant. I work as our senior director of policy. I'm part of the advocacy and access team here at the Arthritis Foundation.

 

Stacy Courtnay:

Thank you. And Nick?

 

Nick Turkas:

I am Nick Turkas. I'm the senior director of patient education and community connections. I've been at the Arthritis Foundation for a long time, but I also spent a little bit of time at an insurance company working with Medicaid and health insurance. So, I love talking about this issue.

 

Stacy Courtnay:

Great. Well, thanks to both of you for being here today. So, we're going to jump right into our questions. Alisa, there are some important changes coming for people on the Medicare drug plan or Plan D. Can you give us a little context about Medicare and why we're discussing this?

 

Alisa Casavant:

So, you're right, Stacy. Starting in 2025, there are several vital changes to Medicare, specifically in the prescription drug benefit — that's Part D, as in dog. Just for anyone new, Medicare is a federal health insurance program specifically for anyone aged 65 and older, as well as some younger folks with disabilities.

 

There are four parts. Parts A and B are considered traditional or original Medicare. Part A is the hospital insurance; Part B is the medical. And then, Part C is that Medicare Advantage plan. It's the alternative to Parts A plus B together. That one is offered by private companies. And then Part D is the prescription drug coverage plan, and that's the one that we're really talking about here. Anyone who is eligible can enroll.

 

Stacy Courtnay:

Alisa, thank you for explaining all that because I honestly had no idea what any of that really meant, A, B, C or D. So, thank you for clarifying that.

 

Alisa Casavant:

Some of the things that we have been advocating for, for many years, include things like affordability. How much can I spend on my prescription drugs in a calendar year? It's really expensive, especially if you're taking specialty drugs. So, along with several major patient and provider nonprofit orgs for many years, we have been working diligently on reforming to make things easier for you to get the meds you need.

 

Part of that includes the Inflation Reduction Act. Congress passed it; the president signed it. It's a really big piece of legislation, but one of the primary things was that it was targeting affordability for prescription drugs specifically. There are two main takeaways that we want patients to make sure that you know. The first one is that there is a new $2,000 prescription drug cap. So, regardless of what Part D plan that you choose, there is a $2,000 maximum for all of your prescription drugs over the plan year.

 

The second key change is a new opt-in program that patients can choose to enroll in that you can then spread out those payments over the plan year. So, instead of paying one massive lump sum for your high-cost drug in March, if you know you're going to spend X number of dollars for the plan year, you can choose to join a new program that lets you make smaller monthly payments for the entire plan year. It's kind of like a way that it makes it easier for you to budget. It’s a really good idea to sign up if you know that you’re going to hit that $2,000 limit.

 

The last one I want to throw out there is free vaccines. Free vaccines for everybody! This is already in place, so you won't have to pay a copay. So, anyone that has a Medicare Part D plan, any of those CDC-approved and recommended vaccines will not charge you additional. So, you can go get your flu shot. You can get your COVID shot. You can get that shingles shot. So, that's a really good big one that started already, and you can go this fall and get your vaccines.

 

Nick Turkas:

And our friends who have arthritis and diabetes, their insulin is capped at $35 per month. So, another great benefit to help save costs.

 

Alisa Casavant:

Definitely.

 

Stacy Courtnay:

Why would someone not choose the payment plan? Is there a reason why they would not?

 

Nick Turkas:

The number one reason why a person would not choose a payment plan is because their prescriptions are already a low cost. Right? If you have prescriptions, maybe you have a generic prescription that you fill monthly. It's a $7, $10 prescription. It's not a burden for you to pay for that.

 

Stacy Courtnay:

OK. So, we talked about those two major changes. How will these changes to Medicare help people with long-term illnesses, such as arthritis, and helping them afford their treatments? Because I know, having rheumatoid, I mean, the bills are astronomical for the biologics that most of us are taking.

 

Nick Turkas:

There are many people, especially those folks that are transitioning from an employer-based insurance, or what we call commercial insurance, right? Those folks that have high-priced medications, typically for inflammatory forms of arthritis, are typically eligible for copay cards. Those copay cards help reduce the cost of the medication, sometimes as low as $5, that people will pay for medications that can cost thousands of dollars. Those copay cards are not available to people on Medicare, and so there's often a big surprise when somebody moves from a commercial plan to a Medicare plan.

 

This new cap will help reduce that giant sticker shock that many people have when they move from commercial to a Medicare plan. Again, a $2,000 payment spread across the course of a year, now that's less than a $200 payment that they would have to pay versus maybe having that medication be totally unavailable if they were expected to pay a large lump sum for that medication all at once. So, that's the biggest benefit for many folks that are having this big transition with their medication and their insurance needs.

 

Alisa Casavant:

I think that's really the number one thing that we're talking about is: the unexpected high out-of-pocket costs, especially if you're new to Medicare or if this is the first time you're enrolling, like Nick's saying. We're constantly hearing from folks that are saying like, "Wow. That was a really expensive bill that I just had to pay, and I wasn't expecting it, because it was covered under my employer when I worked at, you know, X company. Because Medicare pays on coinsurance, which is that percentage. So, instead of a flat dollar copay, such as when I am paying $7 or $50 for my prescription, Medicare uses coinsurance, which is a percentage of the total cost, say 40%, of my drug.

 

Alisa Casavant:

I think it's really, really important here to talk about the fact that 47 million people also have Medicare. We're not talking about a small number of people. So, we really want to make sure we're looking out for all of those individuals who might be affected.

 

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Stacy Courtnay:

So, somebody is new to Medicare, what should they keep in mind during their first enrollment?

 

Nick Turkas:

That's a great question. I would say you really need to be a champion for yourself, to take the time to understand what options are available. And that's the first thing to know: There are options. You have lots of choices. The second thing is: You have lots of help. There are lots of folks that can help you on this journey to making a decision about Medicare. Talking to your physician, your primary care physician, if you have a specialist… Talking to your pharmacist.

 

You can talk to folks that are called navigators, and those navigators will help you make decisions about open enrollment. And those navigators aren't paid for by the insurance company. They're going to help you make a decision that's best for you and not necessarily trying to make a sale. And the Arthritis Foundation. The Arthritis Foundation's Helpline: We have staff that are knowledgeable about insurance, and they can help you make decisions about your health care as well. So, I think that's the first thing that you need to know.

 

And the second thing you really need to decide is: What type of Medicare do I want to enroll in? Do I want to enroll in traditional Medicare? Or do I want to roll into a Medicare Advantage plan? They are pretty significantly different, but that's decision number one.

 

Stacy Courtney:

I do have a sidebar question. So, Medicare, Marketplace... Is that how you refer to it?

 

Alisa Casavant:

Most people get their health insurance through their employer. About 50% of the country, we get it through our jobs or employer. The next group is Medicaid, that's the second largest group. That's geared for folks that are low income. And the third one is Medicare. That's about 15% of the country get their health insurance through Medicare, which again is the people that are aged 65 and older as well as some individuals with disabilities.

 

If I don't qualify for employer and I don't qualify for Medicaid, I make a little too much money, where do I go? And that is the ACA Marketplace. Those are the exchange plans that are purchased either through the federal or state exchanges. That's still private coverage.

 

Stacy Courtnay:

My husband changed jobs. We're rolling off of COBRA in a couple of months, and so we're having to go to the Marketplace for the first time. It's very intimidating and scary, because I've never done this before.

 

Nick Turkas:

It can be a little intimidating. But once you start the process and review your options, you’ll be so glad you did because you’ll have a better understanding of the health benefits that you can use as part of that insurance. And know that when you apply for those Marketplace plans, Stacy, you may be eligible for subsidies to make the cost of insurance much more affordable.

 

Stacy Courtnay:

And how do you apply for that?

 

Nick Turkas:

Actually, when you apply, you will have to put in your income and where you live. And based on where you live and the amount of money that you're taking in, it will calculate that for you, and it will help you make a decision about the plans that are available and the costs. The plans are typically tiered, and so you can see the plans that are available. The good news is that all of the plans on the Marketplace have to provide essential benefits, right? They have to be quality health care insurance. I can't guarantee it, Stacy, but I would bet you that you're going to pay less on a Marketplace plan than what you're paying in COBRA.

 

Stacy Courtnay:

You're probably right about the premium that we'd be paying, but the deductibles are so high. I mean, all of the plans. So that part was very overwhelming.

 

Nick Turkas:

That could definitely be true. You might want to look at ways with high-deductible plans, you often may have the opportunity to access a health savings account, where you can put money pre-tax into the health savings account. And also when you pay for any of those services, you won't be paying taxes out. If you're able to budget for those deductibles, there may be a way that you can help soften some of those deductible costs.

 

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Stacy Courtnay:

How do I find out if the medications that I'm currently taking are on the plans that I'm looking into?

 

Nick Turkas:

The best way to find out if a drug is covered is to check the formulary. Formulary is basically just a long list of all the medications that will be covered by your insurance.

 

Stacy Courtnay:

And that can be found during open enrollment when you're evaluating the different plans?

 

Nick Turkas:

Absolutely. All of the plans should post a list of the formulary that will include all of those medications. You can also ask your pharmacist about the plan's formulary as well.

 

Stacy Courtnay:

OK. For each podcast episode, we ask that people weigh in on the topic on social media. So, for this one, we asked: What keeps you up at night about open enrollment and choosing an insurance plan? Here are some responses that we got. Dr. Stephanie Rosado, she worries about step therapy insurance barriers. Do you want to elaborate on step therapy and how that affects Medicare?

 

Nick Turkas:

When you're enrolling in Medicare, you have an option to choose traditional Medicare or a Medicare Advantage plan. Medicare Advantage plans typically have lower upfront costs, but they have smaller networks, and they have more step-throughs to access health care benefits, including medications typically.

 

Step therapy is something that you are much more likely to find with a Medicare Advantage plan versus a traditional Medicare plan with Part D and a Medigap plan. So, if you are concerned about prior authorization, if you're concerned about step therapy, you may want to think twice about joining a Medicare Advantage plan.

 

Alisa Casavant:

And know that the Arthritis Foundation is working on issues such as step therapy and prior authorization. We know that this is an issue across all forms of health insurance, and we're trying to find ways to make it easier. If you want to get more involved on making the change happen, you can email us at [email protected].

 

Stacy Courtnay:

Great. Another social media user, Tenaciousinme, responded to what keeps her up at night: “Never being sure what I may need coverage for in the next 12 months. Health needs can change so rapidly.”

 

Nick Turkas:

This is a great time to have a discussion with your health care provider. “Hey, doc, it's open enrollment, and I need to make big decisions about my health care. Do you anticipate that I'll need to change my medication? Do you anticipate that I'll need a surgery? Do you anticipate that I'll need to see another specialist for any of the health care needs that I have right now?” If your physician and you feel that there may be a needed change in care, have a discussion about what that could be and look at if any of the recommendations that your health care provider may make about surgery, specialty, medical device, that that may be covered by a new plan.

 

Stacy Courtnay:

Thank you.

 

Alisa Casavant:

Another option that you can do is to look back historically on what you have spent, to get a rough idea. It might not look the same year to year but at least you'll have a general sense of how much you spend.

 

Nick Turkas:

Another thing that you need to consider: Is your income going to significantly change? Right? So, if my income is significantly changing, that may impact my ability to pay for my health insurance or some of the benefits that I need, including prescription drugs. However, if you need extra help for your prescriptions, say even with this spreading of the cost, the $2,000 cap, if that is still going to be a burden, you may be eligible for something called Extra Help.

 

Extra Help is administered through Social Security. And so, again, your navigator can help you. Your pharmacist can typically help you. Usually there's someone at your physician's office that helps with billing that may be able to point you to this. But, of course, call the Arthritis Foundation Helpline and we can give you information about accessing the Social Security Insurance Extra Help program.

 

There are two main ways to access a health care navigator. You can go to healthcare.gov, and there'll be a section on the website to help point you to a local navigator. You can also reach out to your State Health Insurance Information Program. That is a program that's available in every state and they are available through your Area Agency on Aging. You can access them in person or call your Area Agency on Aging, and they will help you find a navigator.

 

Stacy Courtnay:

And moving on to another comment, kind of piggybacking off that: Several people say they worry about medication costs and receiving bills after a doctor's appointment.

 

Alisa Casavant:

I think, like Nick said earlier, it’s important to have that conversation with your doctor upfront. My number one recommendation: Always, always, always read your bill and compare it with your Explanation of Benefits. Don't just pay the bill. Look at it. Does it match with what your insurance says that you are going to owe? If it doesn't, you should call and ask.

 

Nick Turkas:

You can also ask, “If my insurance doesn't cover this, do I have an alternative?” Right? So, they may say, “You know what? There are two medications in this class. I typically prescribe this, drug A. But drug B would work just great for you.” The worst thing that you can do, and it happens all the time, is you go to the pharmacy, it's a high-cost bill, and you walk away, and you don't tell anybody. You don't take the medication. You don't tell your doctor. And now, you're in a situation where you have... The arthritis is going to take over.

 

Alisa Casavant:

And we know it's so critical because when you go to that pharmacy and you're facing that really high, unexpected cost, patients are more likely just not to pick up that prescription altogether. You're more likely to spread out your dosing. “Maybe I'm going to extend... I’m going to half the dose even though my doctor told me I shouldn’t, because I just can’t pick up the prescription.” And like Nick said, the Arthritis Foundation is here to help. We have our website. We have a whole staff at the Helpline here to help.

 

Nick Turkas:

We have a whole section on our website called Prescription for Access. And Prescription for Access is your one-stop shop for all of your insurance questions, access-to-care questions. It's a great place to sort of peruse, review your rights, when it comes to access to care.

 

You can access our Helpline at 800-283-7800 or go online at arthritis.org/helpline. You can also find our toolkit, Rx for Access, at arthritis.org/rxforaccess.

 

Alisa Casavant:

Within that website, we built out new resources this fall, specifically for Medicare Part D, for folks who are looking for, like, “What is the best plan option?” We have a patient FAQ article.

 

PROMO:

Whenever you need help, the Arthritis Foundation’s Helpline is here for you. Whether it’s about insurance coverage, a provider you need help from or something else, get in touch with us by phone toll-free at 800-283-7800. Or send us a message at arthritis.org/helpline.

 

Stacy Courtnay:

My last question: I was going to ask each of you what your top three takeaways are from today's conversation.

 

Alisa Casavant:

My top three takeaways for today… Number one, starting in January, there are big changes coming to Medicare, specifically Part D, the prescription drug benefit. Starting January 1st, you will not have to pay more than $2,000 out of pocket regardless of which Part D plan you choose. That means a $2,000 cap for all of your prescription medications combined.

 

The second is that you have the option to opt-in to a new program called the Medicare Prescription Payment Plan to spread out those out-of-pocket prescription costs over your plan year, but you have to sign up for it. So, if you know that you're going to reach that limit, go ahead and sign up. And my third takeaway is not only do you now get free vaccines, so you don't have to pay that copay. You can go get your vaccine. And since it is vaccine season right now for fall, go ahead and do it.

 

Stacy Courtnay:

Thank you. You're passionate about those free vaccines. (laughter) I love it. OK, Nick, what about you? Your top three takeaways?

 

Nick Turkas:

Top three tips: Read, review and reach out. So, go to medicare.gov. Go to healthcare.gov. Read the mail that comes in about your health care options. You’ll get lots of it. So read it, review it. Think about the options that best fit you, your health care needs and your budget. Lastly, reach out. There are many folks that want to help you. Reach out to your health care provider. Reach out to your pharmacist. Reach out to those navigators. And reach out to the Arthritis Foundation, and we'll help you make the best decision for your health care needs.

 

Alisa Casavant:

Oh, Nick, I love that.

 

Stacy Courtnay:

I know. I love it, too. Well, I will say I have just one major takeaway, and that is that, Alisa and Nick, you're a wealth of knowledge, and I love your passion for this. And I love all that you do for patients who have arthritis or any type of condition. So, like I said, you taught me so much today, and I really appreciate your time and your wisdom and your expertise. I'm sure our listeners enjoyed it as well.

 

Thank you to our listeners. We really appreciate you joining us today for our very, very informative conversation on open enrollment and Medicare. And thank you again to Nick and Alisa.

 

Alisa Casavant:

Thanks so much.

 

Nick Turkas:

My pleasure. Thanks so much.

 

PODCAST CLOSING:

The Live Yes! With Arthritis podcast is independently produced by the Arthritis Foundation. Gifts from people like you make our podcast and other life-changing resources possible. You can donate at arthritis.org/donate. This podcast aims to help people living with arthritis and chronic pain live their best life. For a transcript and show notes, go to arthritis.org/podcast. Subscribe, rate and review us wherever you get your podcasts. If you subscribe through Spotify, leave a comment on their platform, letting us know what you think about this episode. And stay in touch