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Those enrolled in Medicare could see some big changes in coming months. Out-of-pocket costs for a month’s supply of insulin will be capped at $35, and vaccines recommended by the Centers for Disease Control and Prevention will be free beginning Jan. 1, 2023. And for the first time ever, the health care program will be able to negotiate directly with drug manufacturers to lower the price of some of the costliest, brand-name drugs.
Those are just a few of the changes coming to the federal health insurance program open to people who are 65 or older or certain younger people with disabilities.
Anyone who is eligible for the program probably has been inundated with various Medicare health care and drug plan advertising mailers since open enrollment kicked off in October.
Medicare’s annual Open Enrollment Period — which ends Dec. 7 — allows beneficiaries to join, switch or drop their Medicare health and drug plans.
“The average person is overwhelmed by the complexity,” said Sunnyvale insurance broker Matthew Sohn. “Medicare works completely differently than regular group or individual private health insurance because Medicare coverage is a combination of a government-run health program and private insurance.”
The typical Medicare beneficiary has dozens of options and can be deluged with competing plans, he said.
Despite the various program choices, however, more than 70% of Medicare recipients don’t even attempt to explore their options during open enrollment period, according to research by the Kaiser Family Foundation.
For people happy with their existing plan, Sohn recommends double-checking with doctors and specialists to make sure they will continue to accept that plan next year.
For those who want to try comparison shopping, he suggests contacting an independent Medicare insurance broker or going online to the government’s website medicare.gov to see available choices.
“Calling an insurance company directly will give information for their products only — they will not help with comparing different insurance companies,” Sohn said.
Insurance agents may be affiliated with only one insurance carrier. Brokers work with multiple insurance companies, he explained, and are compensated by the companies for the patients they sign up. Sohn himself represents as many as 20 groups, including major carriers Anthem Blue Cross, Blue Shield, Aetna, United Healthcare, Covered CA and Kaiser.
Other sources of Medicare advice can be senior centers or financial advisers, who might be able to recommend a Medicare broker, Sohn said.
During a virtual town hall meeting about Medicare on Oct. 19, U.S. Rep. Anna Eshoo, D-Palo Alto, said for those seeking information about program options, a good source of independent Medicare advice is the government-funded Health Insurance Counseling and Advocacy Program (HICAP), which uses trained volunteers to help individuals.
HICAP for Santa Clara County can be reached at 408-350-3200 (option 2). For San Mateo County the number is 1-800-434-0222. A limited number of HICAP appointments are available through Avenidas. To sign up, call 650-289-5400 or email register@avenidas.org.
Eshoo noted that many of the new Medicare features for 2023, including the insulin price cap and negotiated drug costs, are part of the Inflation Reduction Act signed into law in August.
Negotiated prices for the first 10 drugs — which have not yet been identified but will be named next year — will become effective in 2026. And starting in 2025, under the new legislation, people with Medicare prescription drug programs will not have to pay more than $2,000 in out-of-pocket costs for covered drugs, adjusted for inflation in the following years.
Among the options during open enrollment are Medicare and Medicare Advantage, sometimes called Part C. Those enrolled in Medicare Advantage typically pay lower premiums than those on traditional Medicare and Medigap policies, but they are typically limited to in-network providers.
Redwood City Medicare broker Steve Blandino said most of his clients opt for traditional Medicare over Medicare Advantage because the plan provides a wider choice of providers, he said.
In terms of patient satisfaction and quality of care, there are few differences between traditional Medicare and Medicare Advantage, according to the Kaiser Family Foundation, which reviewed 62 studies published since 2016 that compared Medicare Advantage and traditional Medicare on measures of beneficiary experience, affordability, utilization and quality.
Medicare Advantage patients were more likely to get routine checkups and immunizations, while those in traditional Medicare were more likely to get care in the highest-rated hospitals, the foundation concluded. The Bay Area-based foundation, which has no connection to Kaiser Permanente, specializes in health care analysis for policymakers and the public.
“Neither Medicare Advantage nor traditional Medicare consistently performed better across all quality measures,” the foundation concluded.
By next year, Medicare Advantage is projected to enroll more than half of all eligible Medicare beneficiaries, up from 25% in 2010.
Medicare spending, serving more than 60 million people at $731 billion, accounted for 15% of the federal budget in 2018 — second only to Social Security — and is expected to rise to 18% by 2029, according to the Kaiser Family Foundation.