Episode 75: Medicare, What's New for 2025

The donut hole is going away, and you MAY save money, BUT you may also pay more. It's confusing, so we spoke with Sheri Sisler Moore of Sunshine Insurance Brokerage. You can reach her at sheri@sunshineinsbrokerage.com or 407-920-1323.

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Transcript

Medicare changes for 2025
Robin Rountree: [00:00:00] Welcome to Informed Aging, a podcast about health, help, and hard decisions for older adults. I'm Robin Rountree, a former family caregiver. I've worked in the home care industry and now work for the Alzheimer's and Dementia Resource Center with me as my co host. 
Edith Gendron: Hi, I'm Edith Gendron, Executive Director of Alzheimer's and Dementia Resource Center.
I have 40 years of working with adults, primarily with seniors and elders in need. I am a certified Positive Approach to Care trainer and consultant, and ADRC is a designated Positive Approach to Care agency. 
Robin Rountree: The thoughts and opinions expressed here on the podcast belong to Edith and I, not our wonderful employers and sponsors.
This podcast is a service of the Alzheimer's and Dementia Resource Center. center. We are not affiliated with the Alzheimer's Association. Before making any significant changes in your life or your person's life, please consult your [00:01:00] own experts. Today, we're talking again with Sherry Moore from Sunshine Insurance Brokerage.
Our last podcast episode was like the basics of Medicare. Now we're going to dive into the changes coming in 2025. So if you've downloaded this and it's 2028, this podcast will do you no good at all. But if you're currently shopping for Medicare for 2025, you need to stay tuned. We'll be back right after this. 
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ADRC empowers caregivers with the knowledge, support, skills, and strategies they need to help them confidently prepare for the challenges that lie ahead. To learn more, visit the website ADRCCares. org. 
Robin Rountree: Welcome back. Sherry Moore with Sunshine Insurance Brokerage, your website, so I don't forget, sunshine I N S brokerage dot com. You're an independent person who you represent most of the insurance companies out there. So if you're shopping for Medicare, Medicare supplements, long term care insurance,, anything like that, you can help them out, [00:03:00] but you really specialize in the Medicare.
Sheri Sisler Moore: That's correct. 
Robin Rountree: Okay, so I'm going to recap what I learned from you last time. Uh, Medicare Part A is your hospitalization. That's free. Medicare Part B is like your doctor visits. That is not free. Part D is your prescription coverage, which there's a cost with that. And Part C is the Medicare Advantage plans.
We're not huge fans of that for some people, for other people, it works. So go back and listen to the other episode for all the information on that. But now 2025 is quickly coming. , people are shopping, we're seeing lots of TV commercials. So what do we need to know about Medicare in 2025?
So 
Sheri Sisler Moore: with 2025, um, we are. Continuing to feel some of the changes to Medicare with the Inflation Reduction Act, which actually, , took effect in 2022, the government is in control [00:04:00] of the Inflation Reduction Act, and each year, there are minor changes that are happening. , these go back to previous in office, not to get into politics, but we've seen like the insulins being adjusted previously in other years and capping some of them, not all of them at a 35 co pay for the people that are on Medicare.
But with this year, the biggest thing for 2025 and just FYI, the Inflation Reduction Act will continue until, As of right now, 2032, and we all know that can change. , but the biggest change to the Inflation Reduction Act with 2025 is the prescription drug coverage. So for anybody that is on a standalone prescription drug coverage plan, with a Medicare supplement or maybe not, you don't have to have Medicare supplement too, or even Medicare Advantage where it is looped into that and part of that coverage.
We really are recommending they do a review because with the changes coming, [00:05:00] they have capped many people out there have heard of the coverage gap or the donut hole, which is not Krispy Kremes donuts. It's the donut hole. And if you're on some more expensive brand name prescriptions. you may fall into that coverage gap or donut hole where you're paying full out of pocket for those prescriptions.
So with currently in 2024, , the deductible for prescription drug coverage on most of the plans is 545. There are some plans that it's zero, but you're going to pay a higher premium for those plans. Then you would pay a copay or coinsurance until you reach 5, 030. If you go beyond that, that's where the coverage gap comes into play and you're paying full out of pocket for your prescriptions.
Then you reach what they call the catastrophic phase. , well you stay into the gap until you're at 8, 000 and then after that you're in the catastrophic [00:06:00] phase. Coming in 2025, the deductible is going to be 590 versus 545. Your initial coverage, you will continue to pay the copay and coinsurance up to 2, 000.
So instead of the 5, 030, you're paying up to 2, 000. Okay, I like that. 
Edith Gendron: What's the 
Robin Rountree: catch? Here he 
Sheri Sisler Moore: comes. And then, let me finish real quick, and then we'll go back to the catch. But then, the coverage gap, or the donut hole, goes away. Mmm. Which is actually could be good for the people that are on those high end prescription drugs.
The catch is who's picking up the cost, right? I mean, somebody has to pick up that cost. So we're seeing that cost to be passed along to the manufacturers of the drugs, as well as to the carriers, the insurance carriers that are providing these plans. So with that, even more [00:07:00] reason why to get your review for 2025 because if they're absorbing some of these costs and they also just took a cut, the carriers did, of 2.
9 percent, we are not going to see some of the benefits that were being offered in 2024 to be offered in 2025. So if you're not on any 
Robin Rountree: medication at all, You might be fine not to get a review. I don't know anybody not on any medication at all at age 65 or above, but if that's you, good for you still go see Sherry.
She's lovely. But if you are on any prescription drug on Medicare or age 65 plus, you need to have a good, solid look at your plan in this period of recommittal, I guess you would call it. That's not, That's my name for it. 
 It's um, open enrollment. 
Robin Rountree: Open enrollment. I like my word better.
But I like Rika 
Edith Gendron: recommital it's like renewing those [00:08:00] vows. Do you get a pretty white dress or just 
Robin Rountree: another 
Edith Gendron: diamond? I really like it. Cake. No, I don't want any cake. I want the damn diamond. 
Robin Rountree: Yeah, you got a good point there. So we're, we're shopping around and the commercials are going. And you go to the mailbox and there's a lot of stuff there and you get a text on your phone.
So lots of people are looking for your business. And you think it's best to sit down with an insurance broker, correct? 
Sheri Sisler Moore: That would be my advice because as brokers, whether that is us or someone else, brokers have access to multiple carriers, not just one. And then you can really get a true . Review based on your prescriptions, based on your situation of what it may look like with plan or carrier A versus B versus C, where if I'm just an agent with one carrier, that's all I'm going to show you.
Kind of goes back to your statement about somebody on no [00:09:00] prescriptions may not need a review. We do see people on no prescriptions that are on the highest cost standalone prescription drug coverage when they do not need to be. They, there are much lower cost plans because they were sold by somebody that could only offer that carrier.
Edith Gendron: Speaking of no medication, and I'm not sure this is an appropriate question for this context, but if, when you go to enroll, if you don't need any medication and you say, well, I'm not going to do this prescription drug plan piece. Isn't there a serious penalty for that? 
Sheri Sisler Moore: Yes, for the, for the prescription drug plan, there is a penalty if you do not sign up when you're eligible.
Same with Part B. If you do not take it when you're eligible and you're not on a group credible coverage, you can get penalized by the government for both of those situations. 
Edith Gendron: For a long time. 
Sheri Sisler Moore: For a lifetime. The penalty does not go away. Aw, man. Okay. 
Robin Rountree: All right. So this is [00:10:00] another reason not to do it on your own.
Yes. Yeah. Seriously? Yes. Wow. Good point. Okay, so. It looks like what we would be paying out of our own pockets for medications may change drastically in 2025, depending on the coverage and your company and all of that. But you can kind of see that when they come in and see you. You give the list of medications to you.
I'm on A, B, C, and D. You put it in your magical computer and you go, Okay. These are the plans that are going to cover that best, correct? Correct. Any other big surprises coming in 2025? 
Sheri Sisler Moore: The other part of the changes with the Inflation Reduction Act is the people that may be Originally, in that donut hole or coverage gap in the month or two going into 2025, if you do have a prescription that is 600 or more, they are also implementing a payment plan for you, [00:11:00] um, with that so that you can spread what you owe again, your max out of pocket is going to be 2, 000, but if you're getting hit with, you know, 1800 in a few months, then you might want to spread that over the year.
That is not mandatory that you take it, but it is something that will be offered to those clients that are on those higher prescription drug costs. They would be advised by the plan carrier that it would be available and the pharmacy can help get them enrolled, , or inform them about the program. And it also could be where I might not be on that prescription starting the first quarter, Of 2025, but I might get assigned a new prescription or.
Receive a new script and then need the payment plan. So it doesn't have to be from January to December that you're on this payment plan. 
Edith Gendron: Hmm. So if someone's on an expensive medication and I I barely understand the tier business, right, the tier three and onward. [00:12:00] So now potentially the consumer pays less for that medication because the coverage has changed.
Can the formulary then change and say, well, it used to be a tier three and it would have been a hundred bucks, but we're going to make it a tier five. So now it's 800 bucks. Can they do that? Okay. 
Sheri Sisler Moore: Yes, yes, every year the formularies can change with the carriers 
Robin Rountree: and that's why you recommend a review every year, correct?
Before you make your recommitment ceremony. 
Sheri Sisler Moore: That's correct. And every carrier formulary can be different. And within that is every carrier usually is going to have more than one plan. They might have a lower tiered cost plan and a very high cost plan that might cover those brand names better, but you're going to pay a lot more for that plan every month.
Stand alone prescription drug plans. 
Edith Gendron: Mm hmm. Mm hmm.
Robin Rountree: Is it a good idea, and I know you're not a [00:13:00] doctor, but in terms of shopping for Medicare, to see your doctor annually, like, November to kind of get a read of what prescriptions you'll need in the coming year. Or is it not that big of a thing to worry about?
Because the doctor's offices will get flooded and now you can't get in. And never mind my stupid idea. 
Edith Gendron: Yeah, I don't think it's a stupid idea. I'm just trying to picture there's so many variables, right? There really are. Just look at thyroid medication because that's very commonly taken. Right. Two things, um, you can either take a generic and we won't even go into the clinical efficacy of that, but if you say you want the brand name, that I won't say, but if you take it, you know, um, and that's more expensive.
Even if your doctor says you must have this because the generics don't work for you the way they need to work. Right? So, those kinds of things happen. Um, Yeah. [00:14:00] 
Robin Rountree: And then thyroid can change during the year. Yes, yes. So, yeah. All right. 
Edith Gendron: And quickly, too, sometimes. Like if you have Hashimoto's and suddenly it says, okay, I'm going to deteriorate, boom.
Now you're, um, so your doc in November might say, yeah, everything looks good, but by March you're taking a new medication or they finally say, look, you've got to take the brand name. So it's kind of hard to second guess or say, yeah, I don't know. Maybe if you've never. changed anything for two years. 
Robin Rountree: Yeah, but there are no guarantees and no magic crystal ball to see into the future.
Yeah, unfortunately. All right. So, um, the payment plan, is that interest free? 
Sheri Sisler Moore: It is interest free. 
Robin Rountree: Okay. Well, there's that. 
Edith Gendron: That is going to be helpful to some people. Yeah. It 
Robin Rountree: is. Yeah. But you could also save money if you went on the better plan for that medication, if you know you're going to be taking that.
You could. Correct. Yes. Okay. 
Sheri Sisler Moore: Or generics, like you said, if there's a generic option. Right. 
Edith Gendron: [00:15:00] So you would have to weigh the cost of a higher, Premium against the cost of that expensive medication. 
Robin Rountree: That's why you go see an exorcist. That's too much 
Edith Gendron: math for me. 
Robin Rountree: Exactly. 
Edith Gendron: I need somebody to tell me what 
Robin Rountree: to do.
This and taxes. Yeah. No, thank you. 
Edith Gendron: No, no. After the 1040EZ ended, nah, I'm done. No, no. Done.
Robin Rountree: . So anything else we need to know about? 
Sheri Sisler Moore: I do want to let you know. So if you're on a Prescription drug that is not on a plan formulary or if like any Part B drugs or medications not on the member's plan formulary would not qualify for the prescription payment plan. So the plan is only applicable if it's on that plan's formulary.
Robin Rountree: So that's like some of the new Alzheimer's drugs that are coming out. Very expensive. 
Edith Gendron: Lekembe and some of the new ones. [00:16:00] If it's 
Robin Rountree: not on their plan, then you don't get the payment plan. Correct. 
Edith Gendron: Yeah. That's 20, well, yeah. That's a lot. Um, talk a little bit about insulin. I know that insulin is capped, but I also very quickly, so dangerously, read somewhere It doesn't cover all insulin.
Sheri Sisler Moore: That is correct. If it's a newer insulin, um, and I know that Ozempic is a big one, right? It's really is for diabetics insulin, but it's also being used for weight loss by many, many people, but it's new. So it is not, you know, one that has been around for a while and has been capped at 35. There's Mongero, there's Ozempic.
There's a few of them that you will see will not fall under that 35. 
Edith Gendron: And are those insulins? 
Sheri Sisler Moore: Some of them are. Oh. Either shots. Right. Yeah. Yeah. But, yes. Ozempic is classified to be a diabetic prescription drug, but it's not always [00:17:00] being used for that. No. Certainly not. 
Edith Gendron: Right. 
Sheri Sisler Moore: Any other tips we need to know for 2025?
I just would say again, and I know we've talked about it, but just do your, do your comparisons, find a good broker that you trust, that you feel comfortable with, , avoid the scams, avoid the 800 numbers on the TVs that are going to be out right now through december 15th at least, , because many of those you're just calling a telemarketing company and they don't know all the plans, they're only offering one.
So find a local broker, put it that way, that you can work with, that you can have for life basically that you feel comfortable with. So just 
Robin Rountree: because a man was really good at football does not mean that the insurance that he's telling you is the best. amazing as well. We're 
Edith Gendron: great at basketball. 
Robin Rountree: 100%. 
Edith Gendron: Love you Shaq, but you know.
Hmm. Back to that scam for one minute. Talk to us a little bit about that. Be careful about saying yes when you're talking or [00:18:00] answering the phone.
Sheri Sisler Moore: Yes, we are seeing many of our clients and we're The senior population, unfortunately, getting scammed into something that they, you know, didn't really know that they were agreeing to.
So what we're really promoting is you need to be providing consent to contact for these people to be calling you, um, knocking on your door. If you didn't fill out a piece of paper, they're not supposed to be calling you. What we're seeing at some, some of these numbers, and if you don't know the number we recommend, don't answer.
They'll leave a voicemail if they're trying to reach you. But if you do answer, if they're saying, hi, is this Sherry? And I say, yes, this is Sherry. They've just recorded me as saying yes. And there are carriers and telemarketers out there, not carriers, telemarketers, that will change your plan. Just because they have me saying yes, that's my agreement to change my plan.
So please be very careful. Always ask who is calling. May I help [00:19:00] you if you answer the phone. 
Edith Gendron: Yeah, 
Sheri Sisler Moore: that's so 
Robin Rountree: scary. It is. 
Edith Gendron: And it's so second nature because they're quite clever. 
Robin Rountree: Yeah, yeah. Absolutely. All right. All right. So. Don't just say yes. Never say yes. Never say yes. 
Edith Gendron: Banish it from your vocabulary. 
Robin Rountree: Wow.
Aida is putting down the tough laws. How do you, does that make you feel good? It 
Edith Gendron: does. It makes me feel powerful. 
Robin Rountree: You didn't even say yes. I thought it was going to trick you. Ah, yeah. All right, Sherry. Once again, how, , you are an insurance brokerage and you will do a free review, correct? Correct. To help people make sure they're making the best.
insurance option. How do they reach you? 
Sheri Sisler Moore: They can call 407 920 1323. They can go to our website, www. sunshineinsbrokerage. com, or send us an email over at sheri, s h e r i, at sunshineinsbrokerage. com. And you've got [00:20:00] 30 years of experience in the industry. insurance world. That is correct. 
Edith Gendron: And can you help anyone in the United States or just in Florida?
Sheri Sisler Moore: So we, my team and I are licensed in the state of Florida. Some of us do have non resident license in other states. It's not nationwide or You know, all of the United States, but there are some states that we can help. 
Edith Gendron: Okay. But your advice is across the board, good advice for any state. So find a broker in your state 
Sheri Sisler Moore: that you trust.
If I, or some of the team members that are under me do not have that state, we can pretty much connect them with someone that does. 
Edith Gendron: Ah, good to know. Because 
Sheri Sisler Moore: our upline, who I report to, is nationwide. 
Edith Gendron: Ah, good. We 
Sheri Sisler Moore: have access. Do 
Robin Rountree: snowbirds have to get different policies or just one policy? If they're living in two places during the year.
Sheri Sisler Moore: They'll usually just need one policy, whether that is a Medicare supplement or they'll lean towards a PPO if they're on a Medicare Advantage that provides good nationwide [00:21:00] networks. Good to know. Uh, we will put 
Robin Rountree: your contact information in the show notes. Please make sure to subscribe to our podcast, Informed Aging.
Tell your family and friends about us. If you'd like to support the work that we do at the Alzheimer's and Dementia Resource Center, please go to the website. A D R C cares. org slash donate. You can find us at facebook. com slash informed aging. Today's episode was recorded at ADRC's podcast studio.
That's it for now. We are looking forward to our next visit.