As expected, the start of Medicare Open Enrollment Period revealed major changes in the availability of plans and pricing. The biggest changes are in Medicare Advantage plans and Part D prescription drug plans.
We knew significant changes were on the way because of announcements from major insurers and policy changes from the Centers for Medicare and Medicaid (CMS). Revisions in the law also made an upheaval likely, especially Part D plans.
Preliminary data from CMS issued before open enrollment (which runs from October 15 – December 7) summarized the changes.
There are 6.6% fewer Medicare Advantage plans with prescription drug coverage available in 2025 than 2024. UnitedHealth Group is offering 5.4% fewer plans, and Humana will have 2.5% fewer plans.
An average of 34 Advantage plans will be offered in each county in 2025, compared to 43 in 2024.
The Medicare Advantage plans covering 1.5 million beneficiaries in 2024 are eliminated for 2025, according to an estimate from Medicare insurance broker HealthPilot reported in The Wall Street Journal. Another 3.5 million people are estimated to lose their Part D plans.
CMS emphasized a bright spot. The average monthly premium on Advantage plans will fall to $17.00 in 2025 from $18.23 in 2024. Many Advantage plans still impose no additional monthly premium. (Advantage plan members must pay the regular Part B Medicare premium.)
But premiums are only part of the package. Beneficiaries need to look at total costs and benefits.
Advantage plans are popular partly because they offer supplemental benefits, such as dental and vision care, gym memberships, and more. They also bundle prescription drug coverage in the benefits package.
Because CMS has taken measures to reduce its costs and make Advantage plans less profitable for insurers, many Advantage plans are likely to offer fewer supplemental benefits in 2025 than in 2024.
In addition, premiums aren’t the only cost for beneficiaries. Lower premiums can be offset by higher deductibles and copayments.
When examining Medicare Advantage plans, a key metric is the maximum out-of-pocket cost. This is the amount you’ll pay if you need a lot of medical services during the year and incur a plan’s maximum deductibles, copayments, and premiums.
Even so, the maximum out-of-pocket cost might not be your final figure. The estimate usually does not include your share of any supplemental benefits, such as dental, vision, and hearing services. It also includes only care received from providers in the plan’s network. You pay higher costs for out-of-network care.
Advantage plans also can reduce other benefits, such as the number of prescription drugs covered or the cost of the drugs to beneficiaries.
Another change beneficiaries should be aware of is that some health care providers announced they will not accept or participate in certain Advantage plans.
For example, Sanford Health, a major medical provider in the Midwest, said it would no longer accept Humana’s Advantage plan. Essentia Health said it would stop participating in Advantage plans from UnitedHealthcare and Humana.
Other providers already stopped participating in Advantage plans in 2024, and in a recent survey about 16% of medical providers said they planned to stop accepting at least some Advantage plans in the next two years.
The medical providers say Advantage plans offer low reimbursement rates, deny coverage of recommended treatment too often, and are slow to pay providers.
Medical care is fully covered by an Advantage plan only when the provider is in the plan’s network. For out-of-network care, beneficiaries must pay all or most of the cost.
The doctors, hospitals, and other providers you want to provide care to you might no longer participate in an Advantage plan. Check the list of plan providers during Open Enrollment to be sure key providers you want still are on the list for 2025.
A potential change a beneficiary isn’t likely to learn about until 2025 progresses is that an Advantage plan can deny coverage of procedures and services that were recommended by doctors, forcing patients to appeal the decisions or forego the treatments. Some Advantage plans might change their approval policies.
Part D prescription drug plans also will be very different in 2025. CMS reported that there will be about 25% fewer Part D policies offered for 2025, bringing the number offered to the lowest since the inception of Part D.
Many of the Part D plans being offered have higher premiums, deductibles, and other charges that will increase the out-of-pocket costs of beneficiaries. A plan also might cover fewer drugs than last year or move drugs to different tiers. The tier a drug is in determines the amount the beneficiary will pay for it.
It’s more important than ever for Medicare beneficiaries to study the details of their coverage options during this year’s Open Enrollment. Be sure you know what’s changing from 2024 to 2025.
In the past, beneficiaries haven’t done a good job shopping around and comparing Advantage plans. During Open Enrollment in 2021, 65% of Advantage plan members didn’t compare plans, and 43% didn’t even check the changes made to their current plans, according to the Kaiser Family Foundation.
Some people might want to drop out of Medicare Advantage and opt in to original Medicare.
Be aware that original Medicare has coverage gaps. You can fill most of the gaps by purchasing a Medicare Supplement, or Medigap, policy plus a Part D prescription drug policy. But if you’re not in your initial Medicare enrollment period, insurers might be able to deny you a Medigap policy or charge a high premium based on your medical history. The insurers must issue you a policy, however, if you’re switching to original Medicare because you were in a Medicare Advantage plan that is discontinued.
Beneficiaries often say they have difficulty understanding and comparing plans. That’s why it’s a good idea to work with one or more local insurance agents who focus on the Medicare policies and plans available in your area. Seek agents who research many different insurers instead of agents tied to one or two insurers.
Another option is the State Health Insurance Assistance Program, known as SHIP, a federally-funded program available through state governments. SHIP has trained volunteers who guide beneficiaries through their options and help them make decisions. SHIP is free and open to all Medicare beneficiaries.