Medicare News - Majors Changes For 2025

You may have noticed all the TV and other media advertisements that the Medicare annual enrollment period is currently underway and runs from October 15 through December 7.  Medicare beneficiaries can make enrollment decisions to change their enrollment effective January 1, 2025.

Major Changes for 2025

There are a couple major changes in 2025 affecting Part D prescription drug plans:

1. $2,000 out-of-pocket spending cap for prescriptions

The $2,000-a-year out-of-pocket limit for prescription medications applies to stand-alone Medicare Part D policies and prescription drug coverage in Medicare Advantage plans.

It’s the first time in the history of the Medicare program that people have a cap on how much they have to pay out of pocket in a calendar year.

The $2,000 cap includes deductibles, copayments and coinsurance for covered drugs. It doesn’t apply to monthly premiums or to drugs a plan doesn’t cover.

2. No more Part D ‘donut hole’ or coverage gap

This change simplifies the way Part D works. 

In 2025, Part D plans can have a deductible up to $590. After you pay the deductible, then you pay copayments for your medications until your total out-of-pocket costs reach $2,000.  After your total out-of-pocket costs reach $2,000, your Medicare Part D plan will cover the cost of your medications until the end of the calendar year.

Therefore, it may be prudent for Medicare beneficiaries to determine whether a different standalone Part D plan or one bundled with their Medicare Advantage plan may be more cost effective for them in 2025.

Information on all Medicare plans offered by zipcode can be found at medicare.gov.

EBC Offers Medicare 101 

EBC offers our employer clients and their Medicare eligible employees and/or spouses a Powerpoint Presentation called Medicare 101.  It covers the basics of Medicare such as who is eligible for Medicare, the different parts of Medicare (e.g., Parts A, B, C and D), plan options, when to enroll, and how Medicare works with employer plans.  Medicare 101 may be useful for employees approaching age 65, contemplating retirement in the future, or may be interested in enrolling themselves and/or their spouses in Medicare rather than through their employer’s health plan.

In addition, EBC has Medicare certified agents that can help our client’s employees and/or their spouses to determine what Medicare plan is best for them and their budget as well as assist in their enrollment in the plans that they choose.

Although people already enrolled in Medicare can make enrollment changes during the annual enrollment period, October 15 through December 7 with an effective date of January 1, employees currently enrolled in health plans via their employer can enroll in Medicare effective in any month of the year if they are age 65 or older.  Enrolling in Medicare may save money for the employee and the employer.

New Compliance Changes For Medicare

Employers may have employees and/or their spouses that are eligible for Medicare (usually due to being age 65 or older) who may have questions about Medicare.  It is useful for employers to be aware of new compliance changes for Medicare so they can inform their employees before they talk to agents certified to help them with their Medicare options. 

There are 2 new compliance changes for any Medicare Advantage or Part D (prescription drug) plan with a 2023 effective date:

1.      New Required Disclaimer

“We do not offer every plan available in your area.  Any information we provide is limited to those plans we do offer in your area.  Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.”

In almost all circumstances, agents need to include this disclaimer in their marketing materials, during phone calls, on their website, and during any sales meetings with beneficiaries.  This disclaimer needs to be verbally made within the first minute of a call with a beneficiary to discuss a 2023 Medicare Advantage or Medicare prescription drug plan.

2.      New Recorded Sales Calls Requirement

Also, agents need to record all telephonic sales calls with beneficiaries and retain those recordings for 10 years.  If beneficiaries don't want to have their telephonic meeting recorded then they can meet in person with the Medicare certified agent.

Long Covid and its Impact on Employers

Most people who have COVID-19 recover completely within a few weeks. But some people — even those who had mild versions of the disease — continue to experience symptoms after their initial recovery.

About 16 million working-age Americans have long-term Covid also known as Long Covid, and 2-4 million are out of work because of its ill effects, according to a new report from the Brookings Institution. New data shows long Covid is keeping as many as 4 million people out of work (brookings.edu)

Employers have complained of labor shortages throughout the pandemic, and one reason for the lack of workers is due to the large number of working-age Americans out of work due to having Long Covid.

Long Covid, defined by the Centers for Disease Control and Prevention (CDC) as Covid-related symptoms that last three or more months after first contracting the virus, has turned out to be complicated. It is hard to track and study as symptoms can vary from individual to individual. In addition, symptoms can range from gastrointestinal issues to nerve pain and fatigue.

The CDC in June 2022 estimated that nearly one in five American adults who had Covid-19 still have Long Covid symptoms. Overall, one in 13 adults in the US – about 7.5% of the population – have Long Covid.  Although no local data is currently available, it is fair to assume that Hawaii has a similar proportion of its population with Long Covid symptoms.

Older people and people with many serious medical conditions are the most likely to experience lingering COVID-19 symptoms, but even young, otherwise healthy people can feel unwell for weeks to months after infection.

Common signs and symptoms that linger over time and vary from one individual to another include:

o   Fatigue

o   Shortness of breath or difficulty breathing

o   Cough

o   Joint pain

o   Chest pain

o   Memory, concentration or sleep problems

o   Muscle pain or headache

o   Fast or pounding heartbeat

o   Loss of smell or taste

o   Depression or anxiety

o   Fever

o   Dizziness when standing

o   Worsened symptoms after physical or mental activities 

Although COVID-19 is seen as a disease that primarily affects the lungs, it can damage many other organs, such as the heart and brain as well. This organ damage may increase the risk of long-term health problems.

In addition to difficulties recruiting and retaining employees, employers may experience other impacts from employees with Long Covid symptoms.  Employers may have reduced productivity due to higher sick leave other leaves both paid and unpaid.  For example, employees with Long Covid may meet requirements for short term disability (TDI) and/or long term disability.  In addition, employees may request leave of absences (larger employers may have employees request FMLA or Hawaii Family Leave Law) or resign their positions.  Employers will need to review on a case by case basis to determine if an employee is eligible for disability benefits or leave due to having Long Covid.

We will need more time to experience how big or disruptive the impacts will be on employers from employees who have Long Covid.  It will likely contribute to difficulties hiring and retaining qualified employees and may lead to more employees utilizing sick and unpaid leave.  The impact from employees being absent from work will add to the workload of other employees and may also impact stress, mental health and morale.

More research and data will be available in the coming months as researchers release their findings and reports regarding Long Covid.  For example, Long Covid may be found to continue for years rather than months and may change as the Covid variants change as well. In addition, employees may resign from their jobs or request leave
of absences (larger employers may have employees request leaves as mandated
by the Family Medical Leave Act or Hawaii Family Leave Law). Employers will
need to review on a case by case basis to determine if an employee is
eligible for disability benefits or leave of absence due to having Long
Covid.

Reflection on Hawaii Health Care and Medicare

Its almost the end of another year, hard to believe I have been retired somewhere between 5 and 7 years. That first year I was semi-retired and came into the office at Restaurant Row a couple of days a week. So much has happened in the intervening years: Patient Protection Act aka Obama Care is the law of the land. Employers in Hawaii didn’t get the shock that mainland employers did because the Hawaii Prepaid Health Care Act meant that employers were used to providing health insurance for their employees. With two laws covering health care, Hawaii employees get the most generous benefits. If PPA has a more generous benefit (ie drug coverage, coverage to age 26) then that applies in Hawaii. If the Prepaid has the more generous benefit (ie lower deductibles, invitro, lower maximum out of pocket) that’s what applies in Hawaii. Health care is still extremely expensive.

It will help a good deal if Medicare were able to negotiate drug prices (as does Kaiser and large insurance companies). The reason they don’t at present is because in order the get Medicare Part D through Congress, the administration had to agree that Medicare would not negotiate for lower drug costs. Big Pharma was afraid that if Medicare could negotiate their profits would go down, never mind that US taxpayers already subsidize the drug companies by allowing deductions for research and advertising from their taxes and that other countries pay less for drugs manufactured in the US than Medicare and US companies do. Drug companies have multiple lobbyists for every member of Congress because they like it that way. There is an ad on TV right now with a woman who says that if the law passes that allows negotiation, she won’t be able to get the drug she needs because her doctor won’t decide on her drug, the insurance company will. That ad is deceitful. I have been on Medicare since 2005. With my prescriptions, there are three drugs costing over $5,000 a month and an infusion costing $28,000. My prescriptions were never turned down under my prescription coverage plans. Thank goodness for Medicare and thank goodness for me. Lucky we live Hawaii.

October and Hawaii's Quarantine

Here it is October and I have been quarantined since March.  Like you, I am bored. But I can get outside, I can watch TV, read, listen to music, use social media and email my friends.  Some of our neighbors are not as fortunate because although they may have all of the above they also have young children at home missing out on valuable schooling.  Some of our acquaintances also have terrible financial worries; without a paycheck how do you pay for groceries, rent and mortgages not to mention car payments, water and electricity?

Small businesses are folding and with them all the jobs they have been providing.  In Hawaii, this is particularly dire because our healthcare system, for those under 65, is directly tied to employment. There are 8,000,000 individuals in the United States that have been diagnosed with Covid19.   The disease itself and the side effects such as shortness of breath, heart damage, chest pain, cough, headache, joint pain, scar tissue on the lungs are all pre-existing conditions.  Hawaii is the only state that has outlawed exclusions for pre-existing conditions for group plans. 

Please remember your fellow citizens when you vote.

Koa furniture in Clinics - Who pays for that cost?

When I was a child, we had a family Doctor, Malcolm J. Tear. He delivered both me and my brother and also took care of my mom and dad. We would go to his office, sit on a folding chair (without music or magazines) and wait for Dr. Tear to come out and tell us he was ready for us. When Dr. Tear retired, we started with Dr. Craig. Dr. Craig shared an office complex with our dentist. He diagnosed my mother’s colon cancer and diabetes and delivered my first-born son. No more folding chairs but no receptionist, the nurse would come out when it was your turn.

I’m not suggesting we should go back to folding chairs and a lack of specialists, but I do think we need to look at some of the other factors that are pushing up the cost of health care. We have already talked at length about prescription drugs and the advantage the drug companies are taking on the United States that allows them to deduct their research and their advertising. Drug representatives often earn more than the physicians they sell their wares to. I have mentioned the outrageous salaries of hospital administrators and hospital executives often numbering in many millions of dollars a year (each, not in total).

The cost of MRIs, CAT scans and other durable medical equipment have diagnosed and therefore, saved lives. Specialists are better for many maladies and if you have a heart attack, you’ll be wanting to see a cardiologist. I support advanced technology and providing the best physicians in every specialty, so our healthcare is the best in the world.

I believe that overdoing it in décor is a symbol of “we can do anything because we have the money and we are going to get more.” It is not just the Koa furniture but the philosophy that says a hospital needs a decorator and furniture most of us could not afford for our own homes. There is a woman’s clinic here in Honolulu that mainly does mammograms. The lobby is three times the size it needs to be and there are two receptionists with what looks like, Koa desks. The double glass entry doors are etched with a Hawaiian theme and the comfortable chairs are upholstered with Hawaiian prints. There is a wide selection of reading material. It made me uncomfortable and I changed clinics. The mammogram still hurts and I’d rather not be subsidizing over indulgence in decoration.