At The Learnery/Titan Healthcare, we believe in lifelong learning, continually staying up to date on the latest healthcare developments in order to provide the best possible care to everyone. Sometimes those changes come in the form of new science and skills. Other times, they come in the form of changing regulations.
As of January 1, there are some significant changes coming to Medicare, and healthcare workers need to be prepared. Changes to Part D rules, Medicare Advantage midyear coverage notices and stricter marketing rules, expanded benefits for family caregivers, and access to more mental health providers, are all on the list.
Here’s a rundown of the five key updates and what you can do to navigate them effectively:
1. Farewell to the “Donut Hole”
One of the biggest changes is the elimination of the Medicare Part D coverage gap, also known as the “donut hole.” In 2025, Part D plans can have a deductible up to $590. Then you pay copayments for your medications until your total out-of-pocket costs reach $2,000. This means beneficiaries will be able to spread out the out-of-pocket drug costs over the course of the year, having more predictable and affordable access to prescription medications.
What you can do:
- Familiarize yourself with the new Part D benefit structure so that you are ready to explain it to patients.
- Update any patient education materials related to prescription drug coverage.
2. Out-of-Pocket Cap for Part D
A new out-of-pocket maximum of $2,000 will be introduced for Part D prescription drug plans. This will provide financial relief for beneficiaries with high medication costs and includes deductibles, copayments and coinsurance for covered drugs. It doesn’t apply to premiums or to drugs a plan doesn’t cover. It’s the first time in the history of the Medicare program that people have a cap on how much they could have to pay out of pocket.
What you can do:
- Counsel patients on how this cap can affect their medication adherence and overall healthcare costs.
- Be prepared to assist patients in finding the most cost-effective Part D plans.
3. Fewer Medicare Advantage Plans
The Centers for Medicare & Medicaid Services (CMS) is taking steps to reduce the number of Medicare Advantage plans available. This is aimed at simplifying choices for beneficiaries.
What you can do:
- Stay informed about the specific plan changes in your area.
- Help patients understand how these changes might affect their current coverage and guide them through alternative options.
4. Expanded Mental Health Coverage
Medicare is expanding access to mental health services, recognizing the growing need for these essential services. Before this year, licensed marriage and family therapists, mental health counselors and addiction counselors couldn’t bill Medicare because they weren’t allowed to enroll as Medicare providers. Now more than 400,000 behavioral health clinicians nationwide are eligible. Additionally, Medicare permanently expanded access to telemedicine for behavioral health services. That can help with access to providers, especially in rural areas.
What you can do:
- Stay updated on the specific mental health services now covered under Medicare.
- Encourage patients to seek mental health support when needed and guide them to appropriate resources.
5. Enhanced Caregiver Support
Recognizing the vital role of caregivers, a program for dementia patients and their caregivers that launched this year will quadruple in 2025, serving more of the country. The program, called Guiding an Improved Dementia Experience (GUIDE), provides a 24/7 support line, a care navigator to find medical services and community-based assistance, caregiver training and up to $2,500 a year for at-home, overnight or adult day care respite services. An additional 294 organizations will join this program in July next year.
What you can do:
- Be aware of the new caregiver resources and benefits available.
- Connect caregivers with support organizations and services to help them in their caregiving role.
Stay Informed and Be Proactive
It’s crucial for healthcare workers to stay informed about these Medicare changes so that the public/patients get the most of the system. The Centers for Medicare & Medicaid Services (CMS) website is a good source of information. By staying informed and proactive, you can help ensure a smooth transition for Medicare beneficiaries under these new changes.