By Autumn Gray
Medicare’s Annual Open Enrollment Period (AEP), the time for Medicare beneficiaries to join or switch health insurance plans, begins October 15 and ends December 7. Whether you’re new to Medicare this year or well-versed with the AEP process, local providers advise to take stock of your current and potential health needs before enrolling. Each fall also typically brings some changes to Medicare that enrollees should be aware of. For 2025, they are some of the most significant to occur in decades.
The changes will include a $2,000 cap on out-of-pocket Part D drug costs and an opt-in payment plan that would give enrollees the option to pay out-of-pocket prescription expenses in monthly installments instead of all at once at the time of pickup. Both are the result of the Inflation Reduction Act, which, in part, allowed Medicare to negotiate lower prescription drug prices. (See cms.gov for more details on the nationwide Medicare changes.)
“This is great news for all Medicare beneficiaries. It’s going to be a significant amount of savings,” said Marlene Baca, Blue Cross Blue Shield New Mexico’s (BCBSNM) vice president of sales.
Medicare beneficiaries can pay up to $8,000 out of pocket a year for medications, Baca said, so reaching that $2,000 limit is fairly easy for a lot of people to do quickly. The payment plans should also enable enrollees to budget their expenses more easily.
BCBSNM will have coverage in 31 of the state’s 33 counties as it continues to expand plan and benefit offerings for the coming year, Baca said. Some BCBSNM Advantage Plans will also offer a quarterly $100 credit in the form of a debit card that can be used for over-the-counter products – from Tylenol, to blood pressure monitors, to bandages – at retail pharmacies.
While there is no penalty for inaction during AEP, those who don’t make an enrollment decision will be locked into their current plan for an entire year.
“For most people, if anything has changed this year, either with their current plan, health status or budget, the decision to do nothing could lead to an unpleasant surprise or missed cost savings in 2025,” said Jaren Trost, senior medical director and rheumatologist for Optum New Mexico.
Furthermore, Medicare experts have warned that individuals could see providers of Medicare Advantage plans respond to federal changes by raising co-pays and premiums and/or reducing the formularies covered. So, this year more than most, beneficiaries thinking they want to stick with their current Advantage plan may want to review it closely for unwanted changes.
Since each person/family has unique health and budget needs, there is no one-size-fits-all approach to selecting a plan. According to both BCBSNM and Optum NM, three key steps to choosing the best coverage include:
- Knowing your needs: Determine what’s important to you and if you are getting what you need with your current doctor and health plan. For example, does your doctor specialize in serving adults 65+ on Medicare Advantage plans, and do you wish to remain with your current doctor? Do you see specialists, or are you likely to in the next year? What are your current prescriptions and might some be added? What will your budget be for health care in 2025?
- Exploring your choices: If you are happy with your current provider(s), confirm that they will be in the care provider network for the health plan you choose. Don’t assume that your provider(s), including specialists, will be in the same network every year. Make sure your current prescriptions will be covered. Consider whether you need supplemental coverage such as dental, vision and hearing, and what the premium for those be. If you are Medicare-eligible, Original Medicare does not cover these. However, a Medicare Advantage plan may. Might you require care outside of New Mexico? Review out what’s important to you and which plans fit best.
- Getting professional guidance: Once you have reviewed your choices and determined what your individual needs are, speak with a licensed broker at no cost to you
BCBSNM will be assisting all beneficiaries, not just its members, via walk-in hours at 5701 Balloon Fiesta Parkway from 9 a.m. to 3 p.m. Monday through Friday, October 15-December 6. Medicare beneficiaries may also go to bcbsnm.com/medicare or call 888-723-7423.
“Sometimes you may have many plan options to choose from,” Baca said. “A single health insurer may offer multiple Advantage Plan designs, so it’s best to speak with a broker. … Many of our broker partners are able to predict what (a beneficiary’s) annual out-of-pocket costs will be and help them choose the best plan for their needs.”
Brokers are independent agents that receive payment from plans, so there is no cost for an individual to meet with them.
Another resource for information is Prime Time’s 28th annual 50+ Health Care Expo, scheduled for 8 a.m. – 1 p.m. October 9 at the Embassy Suites Hotel, 1000 Woodward Place NE, near Downtown. A free presentation titled “Medicare 101” is set for 11 a.m., with an opportunity for questions. BCBSNM and Optum NM representatives will also be speaking and have people on hand to help with AEP questions.
The simplest way for many people to start educating themselves, Dr. Trost suggests, is to have a conversation with their primary care physician. For people who need a PCP, he says Optum NM can connect them with a doctor and licensed broker by calling 1-505-262-7000, TTY 711, Monday through Friday, 8 a.m. to 5 p.m. Optum NM partners with United Healthcare, Humana, BCBSNM and Presbyterian Health Plans.
“Optum is a value-based health care delivery network, so we deliver care for different insurance plans,” Dr. Trost said. “Our primary focus is preventive care and access to care. … Our job is to keep you out of the hospital and that’s different from a lot of other health plans.”
