Your guide to Medicare reforms
There are six key Medicare reforms that were passed in 2022 as part of the Inflation Reduction Act. They will take effect in the coming months and years, beginning in 2023. This article was last updated in July 2023.
Below, we outline the reforms, when they will take effect, and what people with Medicare insurance will need to know. We’ve also addressed many of the questions we received from grant recipients and healthcare providers and will update this content as new information becomes available.
If you or a loved one has Medicare insurance, bookmark this explainer about these Medicare reforms and mark your calendar for the long-awaited financial relief. Keep reading to learn more. You can also watch our one-hour educational webinar, which explains the changes.
Overview of new Medicare reforms
Understanding Medicare coverage
These reforms will reference different types of Medicare coverage. You may want to review what is covered by each plan before you read on:
Vaccines
As of January 1, 2023, Medicare Part D plans and Medicare Advantage plans no longer require a deductible, coinsurance, or other cost-sharing requirements for adult vaccines that are recommended by the Centers for Disease Control and Prevention (CDC)’s Advisory Committee on Immunization Practices. This includes the shingles vaccine.
For a complete list of vaccines covered, see the CDC’s vaccine recommendation webpage.
Vaccines currently administered in doctors’ offices and paid for by Part B do not have cost-sharing obligations.
Insulin copay monthly cap of $35
As of January 1, 2023, cost-sharing for insulin products is limited to no more than $35 per month for people with Medicare insurance, including insulin covered under both Part D and Part B. No deductibles apply. Medicare has also started a special enrollment period that will allow people who use a covered insulin product to add, drop, or change their Part D coverage one time between now and December 31, 2023.
Medicare Part D updates
All Medicare Part D plans, both stand-alone plans and Medicare Advantage drug plans, cannot charge more than $35 per month for the insulin products they cover. Please note: plans are not required to cover all brands and types of insulin.
Medicare Part D covers:
- Injectable insulin that isn’t used with a traditional insulin pump
- Insulin used with a disposable insulin pump
- Certain medical supplies used to inject insulin, like syringes, gauze, and alcohol swabs
Medicare Part B updates
As of July 1, 2023, cost-sharing is limited to no more than $35 per month for people with Medicare Part B and Medicare Advantage who get their insulin through a traditional insulin pump.
Medicare Part B (medical insurance) does not cover:
- Insulin pens
- Syringes, needles, alcohol swabs, and gauze
For insulin used with a traditional pump that is covered under the Medicare durable medical equipment benefit, you pay 20 percent of the Medicare-approved amount after you meet the Part B deductible. You pay 100 percent for insulin-related supplies, unless you have Part D.
This insulin Medicare reform also applies to people enrolled in the federal Extra Help program.
Learn more about Medicare insulin coverage.
Expansion of the federal Low-Income Subsidy (LIS) or Extra Help program
Beginning in 2024, there will no longer be a partial program in the Low-Income Subsidy program. Full benefits will be offered to people with Medicare with limited resources and incomes up to 150 percent of the federal poverty level, which in 2023 is $21,870 per year for an individual. With full benefits, the majority, if not all out-of-pocket costs for prescription medications will be covered. People who qualify for Extra Help will pay:
- No deductible
- No premium
- Fixed lower copays for certain medications
If your income for 2023 is below $22,000 ($30,000 for married couples), you may qualify for lower prescription drug costs. Many people qualify for “Extra Help” with Medicare Part D (drug coverage) and don’t even know it.
Medicare.gov has a resource to help you quickly see if you qualify for Extra Help.
You can visit PAN’s Extra Help education hub to learn more about this program and see if you qualify.
You can enroll in the Extra Help program by visiting SSA online at ssa.gov/extrahelp or call 1-800-772-1213.
For one-on-one assistance with Extra Help, contact your State Health Insurance Assistance Program (SHIP) at ShipHelp.org or call 1-877-839-2675 to get the number for your local SHIP.
Elimination of the five percent coinsurance for Part D catastrophic coverage
Beginning in 2024, the five percent prescription cost-sharing obligation for Part D will be removed. Currently, when someone on Medicare has spent around $3,100, they will enter what’s called the catastrophic phase of their benefit. In this phase, they will have to pay five percent of prescription costs for the rest of the year, without a maximum limit. According to a 2022 Kaiser Family Foundation brief, the changes will be like having a cap of about $3,250 for the calendar year.
Annual limit of $2,000 for prescription drug costs in Part D
Beginning in 2025, there will be a hard cap or annual limit of $2,000 for prescription medications. No one with Medicare insurance will spend more than $2000 a year for their prescription medications that are covered under Part D. In the years that follow, the cap amount will be adjusted based on inflation.
This provision does not relate to drugs covered under the Medicare Part B program. Medicare Part B covers drugs that are administered by a doctor, nurse, or other healthcare provider in an outpatient setting such as a doctor’s office. For example, some cancer drugs and injectable drugs are covered under Part B. Read more about the Part D cap below.
Option to smooth out-of-pocket prescription drug costs in monthly installments
Beginning in 2025, each Medicare prescription drug plan, including Medicare Advantage plans with drug prescription programs, must give patients the option to pay for their out-of-pocket prescription costs in monthly installments, with a monthly limit on spending. At PAN, we have called this provision smoothing, as it more evenly distributes costs throughout the year.
Please note that patients will need to enroll in smoothing. Monthly payment plans will not be automatic. Read more about part D smoothing below.
Cost and coverage impacts
Changes to insurance coverage
These changes will not affect an individual’s current Medicare enrollment and should not impact decisions during open enrollment. During open enrollment, we encourage people to select plans that best match their current prescription and medical needs.
The Medicare reforms apply to all Part D plans and Medicare Part C or Medicare Advantage plans that have prescription drug coverage. Medicare HMO plans are included if they offer drug coverage. The reforms do not apply to supplemental insurance or Medigap plans, or Red, White & Blue insurance, which covers Parts A and B of the Medicare program.
| Medicare reforms apply to | Medicare reforms DO NOT apply to |
| All Part D plans | Supplemental insurance |
| Medicare Part C—or Medicare Advantage—plans with prescription coverage | Medigap plans |
| Medicare HMO plans, if they offer prescription coverage | Red, White, and Blue insurance |
These reforms should not impact your medication choices
Medicare reforms, such as the Part D cap and smoothing, apply to all medications covered by the Medicare program, including those on specialty tiers. No drugs are excluded. You will not have to change medications in order to benefit from the Part D cap and smoothing. The Medicare reforms will apply if you are taking a brand or generic medication.
What medication is best for you is a decision between you and your healthcare provider. During the open enrollment period, we recommend that you pay close attention to any changes in your current plan related to medications you may need, and carefully review a potential new plan’s drug coverage and related copays and coinsurance.
Out-of-pocket prescription drug costs after the new reforms
In 2024, after paying the initial deductible, a person on Medicare will pay 25 percent of drug costs. They will have a cap of about $3,250 and will no longer pay five percent of drug costs in the catastrophic phase.
In 2025, after paying the initial deductible, a person on Medicare will pay 25 percent of drug costs. They will not spend more than $2,000 a year in out-of-pocket costs for their prescription medications. (The annual cap amount will be adjusted based on inflation in the years that follow.)
Cost-sharing in the catastrophic phase has been decreased for 2024 and will be eliminated in 2025. Patients will continue to pay copays at the pharmacy counter until they reach the Part D cap of $2,000 in 2025.
Changes to coverage and premiums
The Medicare Part D cap will apply, regardless of what tier the medication is placed on. For the period of 2024 to 2030, increases in Medicare Part D premiums will not exceed six percent each year.
Using discount cards and drug manufacturers’ assistance
By law, drug manufacturer patient assistance programs cannot assist people with federal insurance, including Medicare. Drug manufacturer assistance programs support people who are uninsured and people with commercial insurance. For example, manufacturer coupon cards may be available for those with commercial insurance seeking access to particular branded medications.
About the Part D cap
The $2,000 cap does not apply to prescriptions under Part B
The $2,000 cap only applies to Medicare Part D plans and Medicare Advantage programs with prescription drug plans and does not apply to drugs covered under Medicare Part B.
The cap only applies to covered medications
The Part D cap only applies to medications that are covered by a patient’s Medicare prescription drug plan. Part D plans may choose to not cover certain drugs. However, they are required to cover medications that fall into one of the six protected classes: immunosuppressant (organ transplant), antiretroviral (HIV/AIDS), antidepressant, antipsychotic, anticonvulsant (seizures), and antineoplastic (cancer). Drug plans must cover at least two drugs in other categories.
If you are prescribed a drug that is not covered by your prescription drug plan, here are some options:
- If the non-covered prescription drug is a brand-name medication, ask your doctor whether a generic equivalent might work (if there is one).
- Find out whether there are any other prescription drugs in your plan’s formulary that would be effective.
- Your physician can try a formulary exception, a request to obtain a Part D drug that is not included on a plan’s formulary. If the plan denies the request, there is an appeals process.
- During the Open Enrollment Period, October 15-December 7, evaluate the plans available to you. You might find one that covers your needed medication.
Please note, if you choose to pay for a medication that is not covered by your prescription drug plan, your payment will not apply toward the Part D cap of $2,000.
Tracking payments toward the cap
The patient’s Part D plan or Medicare Advantage drug plan will be tracking costs and will determine when the cap has been met.
Income requirements for the Part D cap
Anyone with a Medicare Part D plan or who is enrolled in a Medicare Advantage program with a prescription drug plan will automatically have a Medicare Part D cap in 2025. There are no eligibility requirements, including income.
About Part D smoothing
When smoothing will begin
In 2025, someone on Medicare with a prescription drug plan will have the option to enroll in the monthly payment plan, either before the beginning of the plan year or in any month during the plan year. Information about how to opt into this program will be provided by the drug plans in educational materials.
Enrolling in smoothing
Smoothing only applies to out-of-pocket costs for prescription medications. Smoothing payments do not include premiums. The opportunity to enroll in smoothing is not income-based. All Medicare prescription drug plans must offer enrollees the option to pay out-of-pocket costs in monthly installments.
Once a patient is enrolled, their monthly payment will be determined based on their out-of-pocket costs and the remaining months in the year. Remember, the annual cap will begin at the same time as smoothing, so the maximum amount a person with Medicare will pay is $2,000 per year.
Here is an example of what smoothing will look like in 2025 when the $2,000 annual cap is in place. In this example, the patient had $12,000 of out-of-pocket costs, but they are only responsible for $2,000 because of the annual cap. The chart below shows that if the patient enrolled in smoothing in January, they would be responsible for monthly payments of $166.
Patients with multiple medications
Smoothing can be applied to several medications. Effective in 2025, no one will pay more than $2,000 per year for out-of-pocket costs related to covered medications in Part D and Medicare Advantage prescription drug plans. Monthly payments begin only after a patient successfully enrolls in smoothing, and the patient will need to make monthly payments for the remainder of the plan year.
Patients who opt in will be able to make monthly payments toward their total out-of-pocket costs, for all their covered prescriptions.
Impacts on PAN grants
No impact to current PAN Foundation grants
The Medicare reforms will not affect grants for those who are currently receiving financial assistance from the PAN Foundation. For providers, the process of enrolling patients in grants will not change.
We know that many patients, especially people living with serious illnesses who need specialty medications, will continue to face high out-of-pocket costs. While out-of-pocket costs may come down for some patients in 2024 and 2025, we know there will still be financial challenges for many.
The PAN Foundation will be here to help the thousands of patients who may not be able to afford treatment for years to come. We will continue to evaluate our programs and assistance amounts each year. Any future changes will be included on our website.
Availability of PAN grants in the future
PAN will continue to provide financial assistance, even after the Part D cap is implemented in 2025. We know that affording $2,000 in out-of-pocket costs for prescription drugs each year will still present financial obstacles for many people. We hope to expand our assistance in new disease areas in the future and, with continued support from donors, our goal is to help even more people living with life-threatening, chronic, and rare diseases.
More reforms are needed
Dental, vision, and hearing benefits for people on Medicare
At PAN, we have long advocated for the expansion of dental, hearing, and vision benefits in the Medicare program. Unfortunately, the Inflation Reduction Act did not expand these benefits.
However, there was good news recently related to hearing aids: more affordable hearing aid options are now available, thanks to a new category of over-the-counter hearing aids established by the U.S. Food and Drug Administration (FDA). Over-the-counter hearing aids are now being sold in stores and online, without needing a hearing exam, prescription, or fitting appointment.
Prior authorization likely to change
While the Inflation Reduction Act did not include changes relating to restrictive utilization management practices, the Centers for Medicare and Medicaid Services has issued rules to improve the process of prior authorization. Once the rules become final, Medicare Advantage plans, fee-for-service and managed care Medicaid and CHIP programs, and Affordable Care Act marketplace plans will be required to streamline the prior authorization process.
The rules require these payers to implement an electronic prior authorization process, shorten decision times for payers to respond to prior authorization requests, and require payers to provide a specific reason for denying a prior authorization request. The rules also include other provisions to boost transparency around the prior authorization process and promote health data sharing overall. The timeline for finalizing the rules is unknown.
Impacts on people without Medicare
In 2021, the American Rescue Plan Act temporarily lowered healthcare costs for most Marketplace consumers by increasing financial assistance based on income level. These short-term subsidies were set to expire at the end of 2022, but the Inflation Reduction Act included a provision that extends these enhanced premium subsidies through the end of 2025.
Additional resources
Stay updated about Medicare reforms
Medicare and your Part D plans should share information about the Medicare reforms before they go into effect. For example, Medicare and some plans have already published information about the vaccine and insulin cap provisions, going into effect on January 1, 2023.
PAN will continue to educate patients and providers about important timelines and next steps. The latest information will be included here on our Medicare reforms webpage.
Learn more with these key resources
- Visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227).
- Visit the National Council on Aging for resources and information about Medicare.
- Contact your local State Health Insurance Assistance Program to receive free, personalized health insurance counseling.
Learn about the Extra Help program
People with Medicare insurance may qualify for the Extra Help program, which helps pay for monthly premiums, annual deductibles, and copayments related to Medicare prescription drug coverage. It is estimated that the Extra Help program is worth about $5,100 per year. To qualify for Extra Help, you must be receiving Medicare and have limited resources and income. You must also reside in one of the 50 states or the District of Columbia. To learn more, visit Extra Help with Medicare Prescription Drug Plan Costs.