As a result of the Inflation Reduction Act (IRA), major changes are occurring in the Medicare Part D retail drug program.  Here is my best effort to explain the changes.  Phases of the program  It is first important to understand the four phases of the program.  Figures change from year to year with inflation so I am outlining the 2024 phases here. Deductible Phase: Here, the Part D member is required to cover all costs of his or her drugs up to the deductible amount.  In 2024, the deductible amount is set at $545.  But remember that both standalone Part D plans (PDPs, who enroll beneficiaries in Medicare Advantage (MA) Part C Only plans or traditional Medicare fee-for-service (FFS)) and MA-Part D plans can lower the deductible in their benefit design.  Some even eliminate it for some or all drugs. Initial Coverage Phase:  Here, costs are split between the plan

The health plan industry has been in turmoil since an April 7, 2024 New York Times article appeared attacking prominent insurers and a data technology vendor, MultiPlan, for seemingly transferring huge out-of-network bills to commercial product patients.  Insurers are already battling major headwinds related to two other issues: So, is the MultiPlan issue yet another front on which health plans may have to fight? The public relations on the article alone has raised lawmakers’ eyebrows. The American Hospital Association has asked the federal Department of Labor to investigate both MultiPlan and large insurers to determine whether they engage in business practices that disadvantage patients and providers under the self-insured ERISA law and regulations. So what does MultiPlan do on behalf of health plans While the data and technology firm has networks and negotiation services, more and more MultiPlan is hired by insurers to scrutinize claims coming in from out-of-network providers

Just recently, the Centers for Medicare and Medicaid Services (CMS) finalized two important notices and rules impacting CY 2025: the 2025 annual rate-setting and policy notice as well as the draft 2025 Medicare Advantage and Part D rule. In this blog, I will write about both the 2025 final rule as well as the policy changes in the 2025 final notice. In my blog on April 4, 2024, I discussed the rate-setting components of the annual rate-setting and policy notice.  That blog is here: https://www.healthcarelabyrinth.com/final-2025-rates-for-medicare-advantage-remain-as-proposed/ . In addition, my February 1, 2024 blog on the draft notice is here and has more details: https://www.healthcarelabyrinth.com/2025-rates-for-medicare-advantage-plans-look-tight/ . They should be read together due to a few changes. In addition to the below, you can see my November 13, 2023 blog on the 2025 Medicare Advantage and Part D rule when it was first announced.  This has additional details but also should be