Some Good News – And Not So Good News – This Health Literacy Month

October is Health Literacy Month. It’s also a good time to start thinking about Open Enrollment. Annual Open Enrollment for Medicare prescription drug coverage (Part D) is October 15-December 7, 2024 for coverage beginning January 1, 2025. Open enrollment is also underway for many employer-sponsored plans. Open enrollment for ACA plans begins November 1, 2024, and runs through January 15, 2025.

Year after year the high and rising out-of-pocket costs of health care, especially premiums, deductibles and copays, have ranked among the top financial worries for American families.

The good news: In 2025, Medicare Part D enrollees can expect some welcome relief from out-of-pocket costs at the pharmacy.

The not so good news: ACA and employer-sponsored plans’ premiums and costs are expected to rise. Many of those employer plans are looking to manage their cost increases by further implementing so-called “cost-sharing initiatives” like raising deductibles, co-insurance, co-pays and premiums and increasing reliance on prior authorization, tactics that lead to higher costs and lowered health outcomes for patients.

Keep reading to learn more about the new Medicare Part D features, and ways to push back against harmful prior authorization denials.

What Medicare Part D Enrollees Should Know

Medicare Part D is a voluntary program that helps Medicare beneficiaries pay for prescription drugs. Rising out-of-pocket costs for prescription medications have resulted in cost-sharing burdens for millions of Americans with Medicare Part D coverage. 

Beginning in 2025, Medicare Part D recipients will never pay more than $2,000 in total out-of-pocket costs for Part D prescription drugs. If they opt into the Medicare Prescription Payment Plan, seniors can spread their Part D out-of-pocket costs throughout the year.

  • What does this mean for Medicare Part D enrollees?
    • Medicare Part D recipients will never pay more than $2,000 in total out-of-pocket costs in 2025 for prescription drugs, even if they don’t opt into the Medicare Prescription Payment Plan.
  • For those who opt into the Medicare Prescription Payment Plan they will pay nothing for their prescriptions at the pharmacy. Out-of-pocket costs for Part D medications will be divided into monthly payments based on a standard formula, which will adjust depending on the patient’s cost sharing to date and the remaining months in the plan year. In addition to any monthly premium costs, patients will be billed each month by their Part D or Medicare Advantage plan for the drug costs they owe.
  • Who will benefit?
    • All Medicare Part D beneficiaries will benefit from the $2,000 cap on total out-of-pocket Part D prescription drug costs.
    • The Medicare Prescription Payment Plan is open to all beneficiaries who opt in. The Plan will most help those who expect to have high out-of-pocket medication costs, especially in the early months of the year.
  • How do I sign up?
    • You can opt in through your Part D or Medicare Advantage plan directly. It is best to opt in during open enrollment as it may take time to process the election if a patient opts in during the plan year.
    • Visit Medicare.gov/prescription-payment-plan or call 1-800-MEDICARE to learn more.

What Patients Should Know About Prior Authorization

Prior authorization requires physicians to secure approval from insurers for needed procedures or medications. The process often results in significant delays in care and dangerous denials for tests, treatments and recommended medications. The result: patients are often forced to delay important tests and treatments or have to pay out-of-pocket for the procedures and medications recommended by their doctors.

With prior authorizations expected to continue as an all-too-common fixture in employer-sponsored and government managed health insurance plans, read more to learn about the importance of appealing care denials.

  • Forcing consumers to delay important tests and treatments or making them pay out-of-pocket for expensive procedures and medications when they have health insurance is outrageous. Forcing patients to wait days, weeks and even months for the procedures and medicines they need can have life-threatening consequences.
  • A recent review of Medicare Advantage prior authorization requests revealed that just one of every ten prior authorization requests that were denied in 2022 were appealed. Importantly though, more than 80% of the denials that were appealed resulted in the insurer partially or fully overturning the denial.
  • How can I appeal a prior authorization denial?
    • Learn more about appealing an ACA health plan decision at Healthcare.gov.
    • If you disagree with prior authorization denial by a Medicare Advantage plan, original Medicare or another Medicare plan, visit Medicare.gov
  • The bottom line: The prior authorization system creates consequences for patients and the delays incurred during the appeal process may have negative health repercussions. Patients should use the tools available to appeal care denials.

Understanding your health care options is crucial during Open Enrollment for 2025 coverage. Annual Open Enrollment for Medicare prescription drug coverage (Part D) is October 15-December 7, 2024 for coverage beginning January 1, 2025. Open enrollment is also underway for many employer-sponsored plans. Open enrollment for ACA plans begins November 1, 2024, and runs through January 15, 2025.

With over 100 million Americans carrying medical debt, it’s critical to understand your health care options. To learn more about how consumers can navigate health care costs and appeal processes, visit Healthcare.gov and Medicare.gov. Visit MapRX for detailed information about 2025 Medicare Prescription Drug Annual Open Enrollment.

Consumers can follow @4qualitycare for tips and updates throughout the month. You can learn more about Consumers for Quality Care at consumers4qualitycare.org/.