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Health Line
6 days ago
- Business
- Health Line
The Medicare Prescription Cap
Prescription cap for 2025 Prescription cap changes Other spending caps In Medicare, two types of plans cover prescription drugs: stand-alone Medicare Part D plans or Medicare Advantage prescription drug (MAPD) plans. Private insurers manage both types of plans, which means the plans have different deductibles, premiums, and coinsurances. But due to the Inflation Reduction Act of 2022, once coverage kicks in, you don't need to pay more than a fixed amount out of pocket per year. What is the Medicare prescription cap for 2025? In 2025, you don't need to pay more than $2,000 per year out of pocket once your drug coverage kicks in. Once you reach this amount, you enter catastrophic coverage. This means your plan must fully cover any further costs. You can also use any contributions you make toward Extra Help toward this limit. This annual cap applies to stand-alone Part D and Medicare Advantage (Part C) plans offering drug coverage, also known as MAPD plans. Does the Medicare prescription cap change annually? As of 2025, the Medicare prescription cap is significantly lower than in previous years. Before the new law took effect in 2024, you had to spend $8,000 before reaching catastrophic coverage. You were in the donut hole once you reached $5,030 until you reached $8,000. That said, the new annual cap eliminated this donut hole. However, it isn't static and changes each year. It may rise to $2,100 in 2026. What other spending caps does Medicare have? Medicare spending caps are generally called maximum out-of-pocket (MOOP) limits. While MOOP limits don't apply to Original Medicare (parts A and B), they do apply to Part C and D plans in other ways besides your overall, annual spending on prescription drugs. For example, under the Inflation Reduction Act, any Medicare drug plan enrollees who need insulin may never pay more than $35 per month. Your plan may have two MOOP limits: one for in-network services and another for out-of-network services. In 2025, you may not spend more than $9,350 for in-network services and no more than $14,000 for out-of-network services.
USA Today
03-07-2025
- Business
- USA Today
Looking to reduce your Medicare costs in retirement? Here are 3 smart moves
There's a reason retirees are often told they can get away with replacing 70% to 80% of their income without needing more. A lot of costs tend to shrink in retirement. Many seniors no longer have a mortgage to pay for and can do more home maintenance themselves since they're not busy working. And not having to report to a job means not spending money on a daily commute. But if there's one expense that tends to increase among retirees, it's healthcare. For a 65-year-old leaving the workforce in 2024, Fidelity puts the average cost of healthcare in retirement at $165,000. And part of that includes expenses related to Medicare. The good news, though, is that you can take steps to lower your healthcare spending as a Medicare enrollee. Here's how. 1. Sign up on time Although Medicare coverage beings at 65, you can sign up a bit earlier. Your initial enrollment window for Medicare starts three months before the month you turn 65 and ends three months after that month. It pays to enroll in Medicare on time not just to avoid a gap in coverage, but also, to avoid surcharges on your premiums. If you don't enroll on time, you could face a 10% surcharge for each 12-month period you were eligible for Part B but didn't enroll. And there can be surcharges if you fail to enroll in a Part D drug plan on time. 2. Understand your plan's benefits inside and out If you decide to stick with original Medicare, you'll need a Part D drug plan to go along with Parts A (hospital care) and B (outpatient care). If you decide to enroll in Medicare Advantage, you should get all-in-one coverage through that plan, including prescriptions. While the rules that apply to Parts A and B are universal for all enrollees, each Medicare Advantage and Part D plan sets its own rules and has its own benefits. It's important to understand those thoroughly so you're able to take advantage of the perks you're paying for without incurring unwanted costs. For example, it's common for Medicare Advantage plans to stick you with higher costs for out-of-network care. In some cases, you might even have to foot the whole bill yourself, so it's important to know what your plan will and won't cover. Similarly, with Part D plans, medications are typically grouped into different tiers that come with different costs. It's important to see what costs you're looking at, since there may be a preferred medication that will result in less out-of-pocket spending on your part. 3. Take advantage of fall open enrollment each year The Medicare Advantage or Part D drug plan you sign up for isn't coverage you're stuck with for life. Each year, Medicare enrollees can make changes to Advantage and Part D plans during fall open enrollment, which takes place between Oct. 15 and Dec. 7. During open enrollment, you can switch from one Medicare Advantage plan to another or even drop Medicare Advantage altogether if you're not a fan. You can also make changes to your Part D coverage. Some people choose to sit out open enrollment because they're happy with their existing coverage. But you never know when a more cost-effective plan might become available. So it pays to do some research during open enrollment each year, no matter what. While healthcare might end up being a large retirement expense, there are ways you can reduce it as a Medicare enrollee. Read up on Medicare ahead of retirement so you can position yourself to make the most of it while shaving down your costs. The Motley Fool has a disclosure policy. The Motley Fool is a USA TODAY content partner offering financial news, analysis and commentary designed to help people take control of their financial lives. Its content is produced independently of USA TODAY. The $23,760 Social Security bonus most retirees completely overlook Offer from the Motley Fool: If you're like most Americans, you're a few years (or more) behind on your retirement savings. But a handful of little-known "Social Security secrets"could help ensure a boost in your retirement income. One easy trick could pay you as much as $23,760 more... each year! Once you learn how to maximize your Social Security benefits, we think you could retire confidently with the peace of mind we're all after. JoinStock Advisorto learn more about these strategies. View the "Social Security secrets" »
Medical News Today
03-07-2025
- Health
- Medical News Today
Medicare appeals process after denial
Original Medicare, Medicare Advantage, and Part D plans can deny coverage for a health service or medication. However, individuals have a legal right to appeal the decision if they think it is incorrect.A person can submit an application form with a statement and some supporting evidence outlining why they disagree with Medicare's will then review the information and either allow or refuse the of Medicare termsOut-of-pocket cost: This is the amount a person must pay for care when Medicare does not pay the total amount or offer coverage. Costs can include deductibles, coinsurance, copayments, and This is the amount of money someone pays each month for Medicare coverage. Deductible: This is an annual amount a person must spend out of pocket within a certain period before Medicare starts to fund their This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, coinsurance is 20%.Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription is a Medicare appeal?People enrolled in Medicare have rights and protections regarding their healthcare services. One of these rights is the Medicare appeals allows a person to appeal a Medicare decision about coverage denial or late payments, such as Medicare appeals process has five levels, each with a separate review process. If Medicare approves an appeal at the first level, the process stops. Alternatively, if Medicare denies the initial appeal, the process can go to the next level, and so individual must collect supporting documents from their doctor or other medical professional to prove their appeal case to Medicare. They will submit these documents and the appeal form to are the reasons for appealing?People have the right to appeal if they disagree with Medicare's decision not to approve the following:a request for a healthcare service, supply, item, or prescription drug that Medicare should covera payment request for a healthcare service, supply, item, or prescription drug they have already received a request to change the amount someone pays for a healthcare service, supply, item, or prescription drugMedicare may deny coverage for the following reasons:The item, service, or prescription drug is not medically individual does not meet the eligibility requirements for does not cover the item, service, or prescription at any time.»Learn more:Understanding a Medicare denial of noticeThe appeal process starts when a Medicare beneficiary receives an official written notice that Medicare has denied coverage. Standard notice types include:Medicare summary notice (MSN): An MSN shows Medicare payments for covered services and items for the previous 3 months. It also indicates whether Medicare denies any item or Beneficiary Notice of Noncoverage (ABN): Doctors, other healthcare professionals, and suppliers issue ABN notices as an advanced warning that Medicare may not cover a service or Nursing Facility Advance Beneficiary Notice (SNF ABN): If someone is staying in a skilled nursing facility and approaching the maximum number of covered days, the facility issues the SNF Advance Beneficiary Notice (FFS ABN): This notice tells someone that Medicare will charge them for a service they had or are due to of Denial of Medical Coverage (Integrated Denial Notice): Medicare Advantage plans and Medicaid issue these notices if they will not cover any part of a Issued Notice of Noncoverage (HINN): Hospitals use this form if Medicare coverage for inpatient stays is of Medicare Non-Coverage (NOMNC): This notice is similar to the HINN, but it refers to inpatient care in an SNF, rehabilitation facility, or hospice. A person will receive this at least 2 days before the coverage the appeal processWhen Medicare sends a notice, it includes information about the appeals process. However, the various Medicare parts have different methods for starting an appeal, as follows:Original Medicare (parts A and B): Usually, people must first complete a Redetermination Request form for an appeal against a decision involving Original Part D: If a person wants to appeal a Part D decision, they will also usually need to begin by completing the Redetermination Request Advantage plans: Different rules apply to Medicare Advantage plans, and a person can contact their plan provider for information about appealing a appeals form requires basic personal information and some details of the claim. People must include details of the service or item they are appealing and why they think Medicare's decision is incorrect. They also need to provide supporting evidence, such as a doctor's letter, test results, or diagnosis notification limitsNotifications of decisions have various time will generally provide a decision within 60 days of receiving the expedited service request can take 24 to 72 hours, and a pre-service request can take 14 appeal levelsThe Medicare appeals process has five levels. If someone disagrees with a decision at any level, the appeal moves to the next level of review. At each level, Medicare sends out a decision letter, which includes details of the next levels are as follows:Level 1: This level is called redetermination. It is an initial review by a Medicare administrative 2: A qualified independent contractor reviews the 3: The Office of Medicare Hearings and Appeals (OMHA) reviews the appeal. The amount of the case must be at least $190 in 4: The Medicare Appeals Council reviews the 5: This is a judicial review by a federal district court. In 2025, the claim amount must be at least $1, can a person win a Medicare appeal?You cannot provide too much information. The more information a person provides, the greater the chance of a favorable outcome.A person should include as much supporting information as possible, including information from doctors, other medical professionals, or fast appealIf waiting for a decision would affect a person's health, they can ask for a fast appeal. An example of the need for a fast decision might be if someone is an inpatient in a hospital or SNF and is concerned that the facility is discharging them too this situation, the person has a right to an immediate review by the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO). The notice includes contact the BFCC-QIO is reviewing the case, the hospital cannot discharge the person, and they can stay in the hospital at no charge. The BFCC-QIO has 72 hours to decide the appeal.A person in a nursing facility or other inpatient setting will receive a notice at least 2 days before the coverage ends. The BFCC-QIO has until the end of the business on the day before an individual is due to be discharged to make a decision about the appeal.»Learn more:How to win a Medicare limits to an appealThe time limits for appeals depend on the Medicare Original Medicare (parts A and B), a person has 120 days from the day they received the notice to Medicare Advantage plans and Part D prescription drug coverage, a person has 60 days after receiving the notice to file an an appealIf a person decides to cancel a Medicare appeal, they should call Medicare at 800-633-4227 (TTY: 877-486-2048). They will need to provide the following information:their full nametheir Medicare ID numberthe date they submitted the appeal formdetails about the appealthe reason they are canceling the appealCosts to appealThe Medicare appeals process does not have any associated can get free help and advice with the appeals process and any other Medicare matter at their local State Health Insurance Assistance resourcesFor more resources to help guide you through the complex world of medical insurance, visit our Medicare monthly premium penaltiesAn individual can also appeal Medicare's penalty enrollment penalty Medicare charges a late enrollment penalty if a person does not enroll in Original Medicare (parts A and B) or Part D when they first qualify or do not have other coverage from another a person had health insurance from an employer but Medicare charged a late enrollment penalty, the person can appeal that decision. The evidence needed to appeal will include proof of adequate coverage comparable to that of Medicare.»Learn more:What to know about Medicare late enrollment monthly adjustment amount surchargeMedicare assesses a person's income as reported on their tax return from 2 years ago to calculate the Medicare Part B and Part D premiums. The Medicare income-related monthly adjustment amount (IRMAA) is a surcharge added to the standard a person disagrees with Medicare's assessment, they can appeal an IRMAA surcharge to the Social Security Administration (SSA).»Learn more:All about Medicare denies coverage of an item or service, an individual can appeal the decision. People must provide proof with a claim and submit this to Medicare with an application appeals process has five levels, each with different reviewers. If the review board refuses an appeal, it will move to the next level unless a person accepts the Medicare decides within 60 days, but people can get a fast appeal if it concerns an inpatient stay and if waiting for a decision could affect their health.
Medical News Today
03-07-2025
- Health
- Medical News Today
What are the Medicare election periods?
In Medicare terms, the word 'election' means enrollment. A Medicare election period refers to the time when a person can enroll in the program. When a person becomes eligible for Medicare, they may sign up for Original Medicare (Parts A and B) during the initial enrollment period (IEP), which is determined by the person's option is the open enrollment period, which runs from October 15 to December 7 each year. During any of these periods, people can sign up for a Part D drug plan or a Medicare Advantage we look at each enrollment period in detail, discuss the penalties for signing up late, and describe how to sign are the 3 enrollment periods for Medicare?Medicare offers three main enrollment periods:Initial Enrollment Period (IEP)General Enrollment Period (GEP)Open Enrollment Period (OEP)In addition, a person may be able to sign up for Medicare or switch a plan during the special enrollment period (SEP).The following table explains the enrollment (election) periods at a glance. The sections below explore each enrollment period in more periodDefinitionIEP• begins 3 months before 65th birthday, ends 3 months after 65 birthday• can enroll in Original Medicare, Medicare Advantage, and Part D plans• individuals must have both Parts A and B in order to sign up for Medicare Advantage or Part DOEP• October 15 to December 7 annually• switch from Original Medicare to Medicare Advantage, or vice versa• join, switch, or drop a Medicare Advantage plan• join, switch, or drop a Part D plan if on Original Medicare MA-OEP/GEP• January 1 to March 31 annually or the first 3 months after enrolling in Medicare• For those with Medicare Advantage: switch to another Medicare Advantage plan or switch back to Original Medicare• For those who missed the IEP: Sign up for Medicare Part B SEP• varies based on circumstances• for those with specific circumstances, such as getting Extra Help, changing address, and losing or changing current coverage• can join or make changes to Original Medicare, Medicare Advantage, or Part D plansInitial Enrollment Period (IEP)The IEP, also called the initial Medicare election period, refers to the 7-month time frame when a person first becomes eligible for this period, a person can enroll in Original Medicare. This includes Part A, which covers care in facilities such as hospitals, and Part B, which covers services and supplies, including outpatient a person also wants to enroll in Part D, which is prescription drug coverage, they can do so during this time. Some people opt for Medicare Advantage (Part C) instead of enrolling in Original Medicare, with or without Part D. Advantage plans are an all-in-one alternative to Medicare Parts A, B, and usually D. A person can enroll in an Advantage plan during the IEP includes:the 3 months before a person turns 65the month in which they turn 65the 3 months after they turn 65»Learn more:How do Original Medicare and Medicare Advantage differ?Open enrollment and general enrollment periodsMedicare offers two OEPs each year. The Medicare Advantage OEP is from January 1 to March 31. This is only for those who already have Medicare Advantage. During the same time period, a person who missed the IEP can also enroll in Part B. In this case, this period is called the GEP. The other OEP is from October 15 to December 7. The rules for signing up during these periods January 1 to March 31, a person may:change from one Advantage plan to anotherswitch from Medicare Advantage to Original Medicare and add Part D, if desiredEnroll in Part B if they missed their IEPFrom January 1 to March 31, an individual may not:change from Original Medicare to an Advantage planbuy a Part D plan if they have Original Medicareswitch from one Part D plan to another In the second open enrollment period, from October 15 to December 7, which is also called the annual election period, a person may:change from Original Medicare to an Advantage plan and vice versaswitch from one Advantage plan to anotherbuy a Part D plan if they have Original Medicaredrop a Part D planSpecial enrollment periodMedicare offers SEPs during which a person can sign up for Original Medicare.A person is eligible under the following conditions:They or their spouse is are insured with a group health plan or union through the SEP lasts 8 months. It starts the month after an individual's termination of employment or termination of group health plan enrollment periods for Advantage plans or Part DA person can make changes to their Advantage plan or Medicare Part D under various circumstances during the length of each of these periods is often 2 months after an individual experiences any situation that example, one situation is a change of address, due to:a move to a new location that is not within the plan's service areaa move to a new location where more plan options are availablea move back to the United States after having lived abroada move into or out of an institution, such as a skilled nursing facilityrelease from prisonSome other situations include:having lost healthcare coveragehaving the opportunity to get other coveragechanges to a current plan's contract with MedicareAn individual can find more special circumstances on the Medicare website. What are Medicare's enrollment penalties?The best time to enroll in Medicare is when a person first becomes eligible. If a person enrolls later, they may encounter penalties. Part AIf a person enrolls late in Part A, they may have to pay a monthly premium that is 10% higher premium may be in effect for twice the number of years that the individual did not have Part A. For instance, if someone is eligible for Medicare for 3 years before they sign up, they may have to pay the higher premium for 6 BThe penalty for enrolling in Part B late may be a premium increase of 10% for every 12-month period that a person was eligible but did not enroll. This penalty is usually permanent, lasting as long as the individual has Part B DMedicare calculates the penalties for enrolling late in Part D in a different someone goes without prescription drug coverage for at least 63 continuous days following the end of the IEP, they may face a calculate it, Medicare multiplies 1% times the national base monthly premium. Then, they multiply this figure by the number of months that the person went without this do I enroll in a Medicare plan?The Social Security Administration's website offers online enrollment for Medicare Parts A and B. Individuals can also sign up by phone at 1-800-772-1213 or visit a local Social Security sign up for Medicare Part D or an Advantage plan, an individual can use this online tool to choose from the plans offered in their area. After selecting a plan and insurance company, a person can:apply on the company's websitefill out a paper enrollment form and mail it to the companyphone the companycall 1-800-MEDICARE (1-800-633-4227)Medicare resourcesFor more resources to help guide you through the complex world of medical insurance, visit our Medicare Medicare election period is another name for a Medicare enrollment period. The IEP is determined by a person's birthday, when they first become eligible for Medicare, and when they can enroll in any Medicare is best to sign up during the initial period. Doing so later on may require a person to face late penalties in the form of higher premiums. Due to various circumstances, an individual may miss signing up when they first become eligible. There is also an open enrollment period from October 15 to December 7 each year. During this time, a person can change or switch their Medicare Advantage plan. They can also switch from Original Medicare to Medicare Advantage or vice versa. This is also the time they can make changes to their Part D drug January 1 to March 31 each year, those with Medicare Advantage can change their plan or switch back to Original Medicare. If they missed their IEP during this time, they can also enroll in Part B.''
Medical News Today
03-07-2025
- Health
- Medical News Today
Does Medicare cover prescription semaglutide in pill form?
Medicare prescription drug plans generally cover semaglutide in pill form. These plans include Part D and Medicare Advantage plans with drug is a type of drug called a glucagon-like peptide-1 (GLP-1) receptor agonist. Manufacturers sell it in different forms under various brand names, and doctors may prescribe it to treat type 2 diabetes, cardiovascular disease, and oral pill form of semaglutide is called coverage for semaglutide in pill formRybelsus has Food and Drug Administration (FDA) approval for treating type 2 diabetes when people combine it with regular exercise and a balanced diet. Sometimes, doctors may prescribe Rybelsus off-label to assist with weight prescription drug plans generally cover Rybelsus when prescribed to help lower blood sugar in people with type 2 diabetes. However, Medicare does not cover Rybelsus for its off-label uses, such as weight drug plans only cover drugs for uses approved by the of semaglutide in pill form with MedicareSince private insurance companies offer Part D and Medicare Advantage plans, their coverage and costs vary. Given this, oral semaglutide costs depend on the details of a person's specific costs include copayments, coinsurance, or deductibles. In 2025, Part D plans have an annual deductible of no more than $590. There is also a $2,000 cap on annual out-of-pocket spending on covered find a Medicare plan that includes coverage of Rybelsus and learn the estimated cost, use the coverage finder tool on more:What is the cost of Rybelsus on Medicare? Does Medicare cover weight loss drugs?Injectable forms of semaglutide include Ozempic and Wegovy. Wegovy has FDA approval for treating overweight or obesity. However, despite Wegovy having FDA approval for this indication, Medicare does not currently cover Wegovy as a treatment for obesity rules prohibit the coverage of drugs used solely for may cover Wegovy to help prevent serious cardiovascular events in people with obesity and cardiovascular disease. This is a newly approved use for the drug as of March 2024.
