Affordable Health Insurance for Families & Individuals in Maine

As Congressional Republicans and President Trump search for trillions of dollars in cuts to mandatory federal spending that could help offset the cost of extending expiring tax cuts, this brief analyzes current support from the federal government for health programs and services, including both spending and tax subsidies as context for those federal budget discussions.

In Medicare Physician Fee Schedule Final Rules from recent years, the administration made changes to Medicare payment policies for certain dental services, in addition to other payment and policy changes. The 2023 rule clarified CMS’s interpretation of when medically necessary dental services can be covered and codified certain payment policies, and the 2023, 2024, and 2025 rules define new clinical scenarios for which Medicare payment can be made for dental services. This brief describes current law related to coverage and payment for dental services under Medicare and the rationale for changes to current policy, explains changes to dental payment and coverage included in these rules, and discusses the impact on Medicare and beneficiaries. While these changes are projected to benefit a small number of Medicare beneficiaries, they do not represent a broad expansion of Medicare coverage of dental services.

Medicare Part D is a voluntary outpatient prescription drug benefit for people with Medicare provided through private plans, including stand-alone prescription drug plans and Medicare Advantage plans that offer drug coverage. This analysis provides an overview of Medicare Part D plan availability, premiums, and cost sharing in 2025 and key trends over time.

This brief provides an overview of premiums and benefits in Medicare Advantage plans that are available for 2025 and key trends over time. Two-thirds of all Medicare Advantage plans with Part D prescription drug coverage (MA-PDs) (67%) will charge no premium (other than the Part B premium) in 2025, similar to 2024 (66%). Nearly all Medicare Advantage plans (97% or more) are offering vision, dental and hearing, as they have in previous years. However, the share of plans offering certain benefits has declined, such as over-the-counter benefits (85% in 2024 vs. 72% in 2025), remote access technologies (74% in 2024 vs. 53% in 2025), meal benefits (72% in 2024 vs. 65% in 2025) and transportation (36% in 2024 vs. 29% in 2025).

This issue brief merged beneficiary-level Medicare and Medicaid data from 2021 to document sources of coverage for dual-eligible individuals nationwide and by state.

Knowledge Becomes Power in Recognizing and Avoiding Scams.

Stars… we like them! The more stars you get, the better you are. It goes back to nursery school and it continues to longevity. Medicare’s 5-Star rating system is all about ensuring that Medicare Advantage Plans and Stand Alone Prescription Drug Plans step up, raise the bar, compete, and do the best job taking care of you. The better the plans perform, the more stars they earn. Every plan’s performance is transparently displayed when you visit www.medicare.gov . When it comes to the cost of healthcare, everyone – that means you and me, along with insurance plans and healthcare providers, must do our part. The truth is, the more proactive we all are with our healthcare, the lower overall healthcare costs. Collectively – not only do we have a part in this, we also have a say in it! The Centers for Medicare and Medicaid (CMS) award all Medicare Advantage Plane and Stand-Alone Prescription Drug plans with a universal star rating system. Plans are awarded stars on a scale of 0 (too soon to tell) to 5 stars being the best. Visit www.medicare.gov and view all the Medicare plans in your area. All of those insurance carriers are competing for stars, and earning those stars, in part, is a result of customer satisfaction and health management. The star rating for Medicare Advantage Plans is based on 38 quality measures in five major categories as follows: Staying healthy: screenings, tests, and vaccines. Managing chronic (long-term) conditions. Plan responsiveness and care. Member complaints, problems getting services, and choosing to leave the plan. Health plan customer service. The star rating for prescription drug plans are rated on 12 quality measures, in four major categories as follows: Drug plan customer service Member complaints, problems getting services, and choosing to leave the plan Member experience with the drug plan Drug pricing and patient safety  When Plans compete for stars, the consumer benefits. Plans are always looking for ways to increase their star rating, especially with Medicare Advantage Plans. These managed care plans carefully balance how they care for chronic conditions while also incentivizing preventive care. In short – it is in the plans interest to get to know you; and what ails you. The more proactive they are with your care; the lower the healthcare costs and the better the healthcare outcomes of members. When plans hit these accountability measures, they get awarded with higher stars. We all know the old adage, an ounce of prevention is worth a pound of cure – this comes to bear in the star ratings of Medicare Advantage Plans. The more members participate in preventive care – screenings, etc., the more stars the plan earns. Members are often encouraged to earn extra rewards by practicing good preventive care. Plans are rated each year. Ratings come out in October for the upcoming year. If there is a 5-Star plan available in your market, Medicare Beneficiaries can join or switch to a 5-Star Plan outside of the Annual Enrollment Period (October 15 th – December 7 th ), by utilizing a one-time SEP (Special Enrollment Period) beginning December 8 th – November 30 th of the next year. Enrollments are effective the month following the enrollment request. There you have it. Stars – they are a good thing, even with Medicare! The star rating system creates competition, accountability, and transparency. The next time your plan calls and offers you a healthy home visit, take them up on it. Together, we can reduce the cost of healthcare by taking preventive steps. And who knows – the plan you are on may give you a reward for practicing good preventive and healthcare management.

Medicare Prescription Drug Coverage – some good news! If you are struggling with the high cost of prescription drugs, you are not alone. More than 5 million Americans are in the same boat. It has always seemed a bit odd that Medicare Prescription Drug plans never put a maximum out-of-pocket cap on Medicare beneficiaries prescription drug spending each year. The good news is, this is changing in 2024! There are four CMS (Centers for Medicare and Medicaid) stages to a Medicare prescription drug plan. Each year the thresholds change. For 2024, the thresholds are as follows: Stage 1 – Deductible: $545 Stage 2 – Initial coverage $5,030 Stage 3 – Coverage Gap (otherwise known as the donut hole) - $8,000 Stage 4 – Catastrophic coverage - $0 cost. New in 2024, prescription drug costs will cap at $8000.00. Putting an end in sight to run away prescription drug costs. That’s a start. In 2025, total prescription drug costs will cap at $2000. That’s a notable improvement. None the less, for Americans living on a fixed income, these cost are still daunting. The Federal Extra Help programs (LIS) is available to help beneficiaries by providing subsidies that result in $0 premiums and lower cost, fixed copayments for covered prescription drugs. In 2024, eligibility for this program is expanding from 135% of Federal Poverty Level, to 150% of federal poverty level . Eligible beneficiaries must also meet statutory resource limits. At last, insulin dependent diabetics will receive financial relief! In 2024, insulin will not be subject to a deductible in any Part D prescription drug plans. Beneficiaries will pay no more than $35/month for each insulin product in the Initial Coverage and Coverage Gap phase. And finally, rest easy. Any vaccines that are recommended by the Advisory Committee on Immunization Practices must be no deductible, and $0 cost. Whether you have your prescription drug coverage imbedded in your Medicare Advantage Plan, or you have a stand-alone prescription drug plan, you should always check your plan’s formulary to make sure your meds are in the formulary. When working with clients, I always use www.mediccare.gov . It is a great resource for consumers to objectively check plans and formularies. If you would like me to review your plan, click here. If you would like to compare plans that I offer and self-enroll, click here. If you would like to learn more about diabetic support programs or check eligibility for Extra Help, feel free to give me a call: 207-544-4119 Medicare disclaimer: Currently, we represent seven organizations which offer 65 products in your area. You can always contact Medicare.gov. 1-800-MEDICARE or your local State Health Insurance Program for help with your plan choices.

The Center’s for Medicare and Medicaid (CMS) have heard you! They know that you don’t like the deceptive ads that flood the airways and your mailbox and they want to reduce the risk of surprises and scams by introducing a cooling off period, where you, the consumer, control when and how you enroll in a Medicare insurance plan. CMS has introduced the 48 Hour Scope of Appointment form. Here’s what this means for you: If you want to enroll in a Medicare plan or change your Medicare plan, you must provide a signed Scope of Appointment at least 48 hours before you meet with an agent. This goes into effect 10/1/2023 . This new Scope of Appointment rule affects how Medicare beneficiaries and agents interact Currently, Medicare beneficiaries have been signing a Scope of Appointment at an appointment Under the new rule, Medicare beneficiaries must provide a signed the Scope of appointment, a minimum of 48 hours in advance. When a Medicare beneficiary signs a Scope of Appointment, they are under no obligation to enroll in any plan. Rather, they are simply giving an agent permission to discuss Medicare products that they are interested in. A signed Scope of Appointment remains open until a beneficiary completes a meeting with an insurance agent. At the end of the meeting, the agent closes the Scope of Appointment, and must retain the signed Scope of Appointment for 10 years. Beneficiaries who have an agent and want to have easy access to discuss Medicare plans at any time with their agent, may pre-emptively sign a Scope of Appointment to be kept open in their file. The open scope expires one year from the date it is signed, or at the completion of a Medicare appointment – whichever comes sooner. The Scope of Appointment can be signed a variety of ways: Paper copy – sign and send back via snail mail; print, sign, scan – fax or email; electronically, or telephonically. There are five boxes, listed on the Scope of Appointment: Medicare Supplement (Medigap) plans, Prescription Drug Plans, Medicare Advantage Plans, Dental/Vision plans, and supplemental indemnity plans. Check as many boxes as you would like to discuss. If you don’t understand how each of these plans work, and you’d like a general refresher course on Medicare, checking all of the boxes allows an agent to present a comprehensive overview.. On the other hand, if you know the different plans, and/or simply want to make a plan change, you may simply check one box. You choose. You are in charge!