Medicare changes take effect in ’19

The new year means a few updates to Medicare, the federal health insurance program for people 65 or older and some younger people with specific disabilities or health issues.

Here’s what you need to know:

Therapy cap is gone

Payment caps for speech, occupational and physical therapy are gone after Congress voted in February to permanently repeal them. For the last two decades, there was a limit on how much Medicare would pay each year for these services — but Congress would typically pass waivers for services that were deemed medically necessary.

But in 2017, federal lawmakers failed to renew the waivers, creating a wave of uncertainty for Medicare beneficiaries who rely on the services until February 2018, when the caps were canned for good.

“Before the act was passed, there were millions of people who were probably going to reach those caps,” said Wesley Prater, associate state director of advocacy for AARP Ohio. Had that happened, observers believed many beneficiaries might have been unable to afford the therapy services.

The permanent repeal is significant, Prater said, because it eliminates the possibility of waivers again expiring without action and instead offers certainty to

original Medicare beneficiaries that “can afford to get the therapies they need.”

Doughnut hole (partly) gone

The so-called “doughnut hole” coverage gap under Medicare Part D has partly closed in 2019 — a year earlier than expected — lowering the annual amount some will pay for name-brand prescription drugs.

The doughnut hole kicks in after the amount you and your drug plan have paid for prescriptions in your initial coverage phase exceeds a certain amount. In 2019, that amount is $3,820.

In the past if you passed that threshold, you typically would have had to pay a higher percentage of drug costs than you would have under your plan’s co-pay or co-insurance. That percentage was 40 percent in 2017 and 35 percent in 2018.

Now, if you enter the coverage gap, known as the doughnut hole, you will be responsible for 25 percent of the cost for name-brand drugs.

Under the Affordable Care Act, the doughnut hole was set to shrink to the 25 percent figure in 2020, but Congress sped up the timeline in its 2018 budget deal.

However, the coverage gap

for generic drugs remains in 2019, with Medicare beneficiaries responsible for 37 percent of the costs. It will be lowered to 25 percent in 2020.

More supplemental benefits

The range of supplemental benefits covered by Medicare Advantage plans, which are offered by private insurance companies, is increasing in 2019. Offerings now include nicotine replacement therapy, family caregiver support and personal-care services such as housekeeping and transportation assistance.

But not all plans will initially carry these expanded offerings. An AARP analysis found that about 47 percent of Medicare Advantage plans in 2019 offer the nicotine replacement therapy, while family caregiver support is offered by 13 percent and personal-care services by 3 percent.

Experts believe those percentages will rise in the future, especially for personal-care services, because “that’s certainly a benefit people are looking for,” said Christina Reeg, director of the Ohio Senior Health Insurance Information Program (OSHIIP), an arm of the state Department of Insurance that offers education and guidance

to Medicare beneficiaries.

Before looking at what supplemental benefits Medicare Advantage plans offer, Reeg said to make sure your plan covers the medically necessary services you expect to need — such as a critical prescription or that your longtime doctor is considered in-network.

Medicare Advantage enrollment window

If you’re among the one-third of Medicare beneficiaries enrolled in a Medicare Advantage plan, there is good news for you: your window to switch plans is now open until March 31.

Previously, you only had until Feb. 14 to drop your Medicare Advantage plan and enroll in original Medicare, said Semanthie Brooks, a member of AARP Ohio’s executive council who speaks to older adults across the state about Medicare.

You’ll also have the chance to pick a new Medicare Advantage plan, Brooks said.

She said this change is beneficial, for example, if you didn’t realize until January that one of your necessary prescriptions is no longer covered by your Medicare Advantage plan.

kstankiewicz@dispatch.com @kevin_stank