Good News (Mostly) About Medicare, Starting in 2019

Medicare, the government program for seniors that is the basis for the recent “Medicare for All” political rallying cry, has some news of its own to announce for 2019. According to the Center for Medicare and Medicaid Services (CMS), several improvements in Medicare take effect this year, with some applying to all recipients and others only to those on a Medicare Advantage (MA) plan.

When signing up for Medicare, you must choose between Original Medicare (Parts A and B) and Medicare Advantage, an all-inclusive private plan that provides regular Medicare coverage along with prescription drug coverage and some attractive extras such as dental, vision and hearing. Many who choose Original Medicare also get one of 10 Medigap plans for part or all of the 20% or so that Medicare doesn’t pay, along with a Medicare Part D prescription drug plan.

Medicare Advantage plans typically provide more benefits with lower premiums. The downside is that MA plans require you to choose “in network” providers. If you go outside the plan’s network or geographical area, you may pay more or not have coverage at all. Many Part D drug plans also have a network with similar restrictions. The table below outlines basic coverage provided by each type of Medicare plan.

For 2019 the amount you pay per month in premiums, deductibles, coinsurance and copay amounts will change as follows:

• Part A Premiums – For the 1% of beneficiaries who pay them, Part A premiums will range from $240 to $437 per month in 2019, an increase of $8 to $15 based on the number of quarters of coverage you had. Your Part A deductible rises $24 to $1,364 in 2019.
• Part B Premiums – For most beneficiaries, Part B premiums will be $135.50 in 2019 versus $134 last year. The Part B deductible increases $2 to $185.
• Medicare Advantage Premiums – These will fall 6% on average to $28 for 2019. Some MA plans have no premiums (with skimpier coverage), but with MA plans you must also pay your Part B monthly premium and stay within the plan’s network.
• Part D Drug Plan Premiums – These are expected to drop about $1.09 in 2019 to an average of $32.50 per month. The maximum allowable Part D deductible will increase from $405 to $415 in 2019.

The Medicare & You handbook, which the agency sends to beneficiaries every year, has been updated for 2019. This year’s edition includes checklists and flowcharts that make it easier to evaluate coverage. In addition, the online Medicare Plan Finder tool has been updated, along with an improved “coverage wizard” designed to help you compare costs and options between Original Medicare and Medicare Advantage.

Telehealth services, which allow patients to connect with medical professionals via video conference, now cover those with end-stage renal disease or undergoing treatment for a stroke. This is important for seniors with mobility problems who may previously have delayed going for treatment for those reasons.

If you have Original Medicare, you will no longer be subject to a cap on outpatient physical, speech and occupational therapy. Historically, Medicare has limited the amount of coverage you had for those types of services.

Under the Affordable Care Act (ACA) the doughnut hole (gap between initial and catastrophic coverage) was scheduled to close in 2020. Congress moved that closure up to 2019 for brand-name drugs. This means once your drug costs exceed $3,820, you’ll pay just 25% of the cost of brand-name drugs (compared to 35% in 2018) and 37% of the cost of generics while in the doughnut hole. Once your costs exceed $5,100 for the year, you’ll pay just 5% of the cost of all drugs under catastrophic coverage.

Many Part D prescription drug plans will offer lower premiums and copayments if you agree to use a pharmacy in the plan’s network. Otherwise, you may pay a lot more. Before signing up for a Part D plan, find out if it includes preferred pharmacies and if your favorite drugstore is in the network.

Beginning in 2019 Medicare restricts initial opioid prescriptions to a seven-day (or less) supply. Additionally, if your daily dosage exceeds a set amount, the pharmacy must contact the prescriber for the claim to be paid. If a patient is identified as “at risk” for opioid abuse, Medicare will contact the prescriber to determine whether a drug management program should be utilized.

A number of helpful changes went into effect in 2019.

Improved MA Plan Enrollment Period

You now have up to three months (Jan. 1 to March 31) to try your Medicare Advantage plan and switch to another MA Plan or even switch to Original Medicare. Previously you only had about a month and a half (Jan. 1 to Feb. 14). If you revert to Original Medicare, you also have the option to sign up for a Medigap and/or Part D drug plan. For more on enrollment plan options, see the National Council on Aging’s fact sheet.

MA Plan Expanded Network Coverage

Some MA Plans are providing more expansive coverage for the use of out-of-network providers for 2019. In most cases this improved coverage comes at a higher cost. Choosing one of these plans could make sense if you want to be able to use out-of-network providers with an MA plan.

MA Plan Expanded Choices

About 600 new Medicare Advantage plans are being added in the U.S. in 2019. The CMS says more than 91% of Medicare recipients will have access to 10 or more Medicare Advantage plans, and in some areas the number of Part D prescription drug plans and options will increase as well.

MA Plan Lifestyle Support

As of this past January, MA plans have the option to cover nicotine replacement therapy, diabetes, congestive heart failure, meals delivered to your home, transportation to a doctor’s office and certain safety features, such as bathtub grab bars and wheelchair ramps. If your plan provides this coverage, you will need the recommendation of your doctor to obtain it.

MA Plan Home Health Care

MA plans can also elect to pay for home health aides to help with dressing, eating, personal care and other daily activities. As with other types of lifestyle support, your doctor must recommend coverage for you.

MA Plan Step Therapy Option

Also new for 2019, MA plans have the option to apply step therapy for certain doctor-ordered and Part B drugs. This means you may be required to try a lower-priced medication before the plan approves a higher-priced medication to treat your condition. If your MA plan has elected step therapy, it must offer a drug management care coordination program and may offer you incentives, such as gift cards, to encourage your participation.

Familiarize yourself with the changes listed above and watch for changes in the works for 2020 and beyond, including plans to mandate lower drug prices and offer even more services to Medicare beneficiaries.