Medicare 360 November 3 2025 Host Jennifer Ly

Episode Transcript

Speaker 1 (00:01):
Welcome to Medicare three sixty, where the world of Medicare
is simplified and you are empowered to make informed healthcare choices.
With over two decades of experience and insurance and financial solutions,
host Jennifer Lee guides you through the ins and outs
of Medicare, whether you are nearing retirement, navigating your options,

(00:22):
or just curious about what's available. Everything you need to
know is covered. Tune in for expert insights, tips and
answers to your burning questions so you can take charge
of your health and your future. And now Medicare three sixty.

Speaker 2 (00:45):
Welcome to Medicare three sixty radio show where we've been
clarity and confidence to your health care decisions. I'm your host,
Jennifer al Fonso Lee, and today we're talking about something
that affects seniors. What's changing and what's critical to know
about Medicare right now between rising healthcare costs, plan changes

(01:09):
and new technology and Medicare services twenty twenty five and
beyond are shaping up to be pivotable years for seniors.
So whether you're on Medicare or about to enroll, or
helping a loved one navigate their coverage today's show will
walk you through what's new, what's next, and how to

(01:32):
protect your health and finances. Let's start with the big picture.
Medicare is evolving faster than ever before. The last few
years brought significant changes from prescription drug reforms to telehealth expansion,
and now increase focus on preventive care and out of

(01:53):
pocket savings. The Inflation Reduction Act has already started lowering
insulin to thirty five dollars a month and putting a
cap on out of pocket drug costs spending. In twenty
twenty five, seniors will final see a two thousand cap
on prescription drug costs under Part D, which is a

(02:17):
huge relief for many retirees living on fixed incomes. In
twenty twenty six, the cap rull increase to twenty one hundred.
While some costs are going down, other costs are going up.
Medicare premiums, copays, and hospital deductibles continue to climb, and

(02:38):
not all advantage or supplemental plans handle those increases equally.
So today I want to help you make sense of
these shifts and understand how to keep your plan working
for you and not against you. So let's dive into
the changes that most seniors are feeling prescription drugs. In

(03:03):
the past, many clients told me they skip medication because
of costs, and that's changing because starting this year and
continuing through twenty twenty five and through twenty twenty six,
there is a two thousand annual cap on out of
pocket prescription drugs in Part D, then also increasing to

(03:27):
twenty one hundred in twenty twenty six. Medicare can now
negotiate drug prices directly with manufacturers for some of the
most expensive drugs in the catastrophic coverage sphase, that confusing
donut hole is being eliminated. This means more predictability and

(03:48):
less sticker shock at the pharmacy counter. So if you
are in a Part D plan or Medicare advantage plan
that includes drugs, now is the time to review your
medications make sure your plan's formulary still covers them at
the lowest costs. And what is a formulary. The formulary
is a set of prescription drugs that are covered within

(04:11):
the insurance company's coverage. And then there's also the tiers,
which will be the tier ones which are the preferred generics,
Tier two which are generics, Tier three, your brand name
and Tier four sometimes specialty with the fives. So plans
change every single year, so don't assume your coverage from

(04:33):
last year. We'll look the same next year. The biggest thing,
if you really think about this, is that before there
was an eight thousand dollars cap on prescription drugs, there
is that dreaded doughnut hole where you're paying an arm
and a leg for your drugs and then you just
start quite getting up to it. So I know this

(04:56):
sounds great, but for those people that orn't hitting their
donut hole, I'm tending to notice that prescription drugs are
more costly. There are some plans that they never had
a deductible for prescription drugs, which next year actually is
going to increase to six fifteen. Some are going to

(05:19):
add that deductible or some type of a deductible for
maybe the Tier three drugs. Some might be quite a
surprise for seniors. So that's why I urged the plan review,
just to make sure that your prescription drugs are going
to be cost efficient for you and you're not going

(05:41):
to have surprises come September first and you have a
sticker shock on how much your drug costs because there's
a deductible or now the cope or the consurance is
a percentage instead of a fixed amount, or your drug
might not even be which would be devastating for those

(06:04):
that their drugs cost very very much. Okay, so let's
move on to access to care, because having insurance doesn't
mean much if you can't use it. In twenty twenty five,
Medicare advantage plans were tightening up networks to manage costs,

(06:25):
especially in high density areas like southern California. Some clients
are finding that their favorite doctors or hospitals suddenly listed
as out of network. And if that's you, don't panic,
but check your provider list early each year. You could
switch during the annual enrollment period. You could also explore

(06:46):
Medicare supplemental plans if you want broader provider access. So
the rule of thumb is you, if you value your
flexibility and want to see any doctor who accepts Medicare,
consider original Medicare with a supplemental if you prefer lower
upfront costs and added benefits like dental vision or hearing. Hey,

(07:08):
Medicare advantage plan might be right, but review the network closely,
and just to add on this. It has been tough
for the last few years. If you are on a
HMO where you have one primary doctor that refers you
to specialists within the same medical group. What's been happening

(07:32):
with the landscape is that there are many contracts up
for renewal, and insurance companies and medical groups are negotiating
on their contracts. Some are on a stancill, some are
playing ball, some want to work with each other, some
really don't. Just never know. So what's happening in on

(07:56):
the landskscape depending on the region you are state the
counting that you are. This has been like an ongoing
thing which is just more pertinent the past few years.
And unfortunately, some of these contracts are up not even
during the end of the year where you could make

(08:17):
a change, which is so odd. I mean, I think
they should make that into rule later on that contracts
should be negotiated and if anything is any seniors are affected,
we should have it at the end of the year.
But that's just a side comment. So what I'm seeing
is contracts are ending, right, So this puts a senior

(08:39):
in a buying number one. First, if you're not reading
your mail or you're not answering your phone and your
medical provider doctor may be calling you and maybe they're not,
but you may have an appointment next month and your
doctor's not in network or medical group, right, I'm of
course by law, there are supposed to send you these

(09:03):
letters in the mail, so please read them. I know
sometimes it gets lost or you just think it's nothing,
but definitely review your mail just to make sure, like
if there are any changes, they give you some ample time.
But it's just been an ongoing thing. Example, there was

(09:24):
a medical group an insurance company and talks for months
sounded like one the medical group did not want to
work with this insurance writer, but the insurance pro writer
sounded like, no, it's everything is going well and we'd
love to stay with them. So that week where that

(09:46):
deadline of the contract was going to happen, the medical
group called all of their clients to tell them that
the contract was going to end. So guess what. Of
course everyone's panicking. They want to make sure that they're
in that medical group or in that hospital. So fortunately

(10:08):
there was things we could do to help them out.
And it was just kind of like mid month or
towards the end of the month, come Sunday or Monday morning,
there's a communication where you know all as well, and
they actually negotiated and they're going to keep that contract.
But look at all those clients, right, all those patients

(10:32):
that were stressing over nothing, some state, some move plans,
things like that. That's why having a licensed independent insurance
agent to help guide you through that process is definitely
worth it all that aggravation. And for us, I mean,
I'm good at change, but definitely that's just how we

(10:57):
don't want things, but unfortunately we can't control it, right,
so it's better to get informed. So enof on that soapbox,
let's get into telehealth and technology and medicare. So one
of the silver linings from the pandemic was the growth
of telehealth and medicare has kept many of these benefits

(11:20):
in place. Today, you can meet with your doctor virtually
FRA a wide range of services, from mental health check
ins to routine follow ups. This has been typically helpful
for seniors in rural areas or those mobility challenges. Beyond telehealth,
medicare is also embracing digital tools, online portals, my medicare

(11:43):
dot gov account and apps attract your coverage and prescriptions
but when that convenience comes risk. Scams are on the rise,
often pretending to be Medicare representatives asking for your information.
Here's my advice, Medicare will never call her text you
asking for your social securitor bank details. Always verify any

(12:07):
call through one eight hundred Medicare or your local licensed advisor,
like our office at Premierey sixteen. So I was just
talking to a client last week and she said, Jennifer,
someone called me and they said, Hi, you have a
plan with X insurance company. We just need to verify

(12:29):
your birthday, and they had her birthday right. But this
lady was sharp and smart, and she's like, I do
not have a plan with you and just hung up
the phone. But imagine, right, you just really don't know
what you have, or you know, you're just caught on
an off guard moment where you believe this person because

(12:52):
they sound trustworthy and basically you think you're talking to
someone at that insurance company, or you're even maybe talking
to your local license insurance brokerage firm that you think
that the advisor is or that team member is part
of that company that you're with, right, that broker So

(13:13):
things like that, I see it often and all the time.
It's very unfortunate why there's so many scams, and that's
why sometimes logging on Social Security just has so many steps.
But I get it. Everyone wants to keep your your
information safe. I definitely just don't talk to any random person.

(13:38):
And they're really good. They they'll give you your information,
they'll tell you what you're on, right, they'll have your
birthday and your address, So just be very leary. And
sometimes I would just say, why don't you I would say,

(13:58):
just okay, if that's the case, I will hang up
the phone on you and I will talk to I
will call you back, right because you definitely have your
insurance agent's number, so you should just call that just
to verify. And that's what usually clients do because you

(14:19):
just never know. It's very important to not get your
information in the wrong hands and then they change your
plan and then like your drugs, change your benefits, all
the costs. So be very leary. Okay, So let's move

(14:39):
on to the importance of annual plan reviews. Here's one
of the biggest mistakes I see every year. People don't
review their plans because it worked last year, but plans
change premiums, the formularies, the networks, even maximum out of pockets,
and also the big one, the benefits. I've seen so
many clients that rely on that grocery or that utility

(15:02):
card and it's not eligible next year. And like even
even gym membership, some plans are cutting back on that.
So definitely like just review it. Just make sure that
all in all is good. So a plan that was
perfect in twenty twenty five may not be the best

(15:23):
fit for twenty twenty six. Each October through December seventh,
during annual enrollment, you have the opportunity to compare new
Medicare advantage plans, review Part dcoverage, or even return your
original Medicare if it's better for your situation. So I
do encourage my clients to schedule a fifteen minute Medicare

(15:44):
review every year because sometimes one small key change can
save hundreds of dollars. So let's talk about something that
often gets overlooked, mental and emotional health. Medicare now covers
a wider range of mental health services, including virtual therapy,

(16:04):
group counseling, and preventive depression screenings. Many Medicare advantage plants
also include like wellness programs, fitness memberships, and even nutrition counseling.
But please look because some of these things are going away.
It's just not about treating illnesses anymore. It's about staying healthy,

(16:26):
active and connected. I always remind my listeners Medicare isn't
just an insurance card. It's your wellness foundation. Use those
preventive benefits, your annual wellness visits, screenings, vaccines. They're included
at no costs. I know some just don't like to
see the doctor, but what's just one visit. Just make

(16:46):
sure everything's in the up and up before it's too late. Right.
The biggest thing is sometimes if you're not if you're
not really going with your gut on what your body's
telling you, sometimes it may be too late. So don't write.
It's better to catch something early than later. Okay, Now,

(17:10):
let's shift gears for a moment and talk about income
related costs because many retirees are subjected when their Medicare
premium jips up unexpectedly. If your income is above a
certain level, you may pay an extra feel called IRMA,
which is the income related with the adjustment amount. It
applies to Part B and Part D premiums and It's

(17:32):
based on your tax return from two years ago. So
if you're retired recently or had a one time spike
in income from selling a home or business, you might
might be paying more than necessary. The good news is
you could appeal irma if your income has gone down
to retirement, divorce, or loss of income. Working with an

(17:53):
advisor who understands both Medicare and financial planning like we
do here at Premiere three sixty can help. You could
coordinate with benefits with your track tax strategy. So yeah,
biggest thing is, especially if you have to start taking
required minimum distributions that might affect selling your home, might

(18:16):
affect your adjusted gross income. So just at least no right.
No one likes to be caught off guard in surprise
on how much they have to pay if they don't
have to. So again I think I really want to
touch it again. The scams and frauds. Sadly, Medicare fraud

(18:39):
continues to rise, especially during open enrollment. Scammers no seniors
are comparing plans and they use that confusion to take advantage.
So some pretend to be Medicare agents offering free upgrades
or new benefits. Others may ask for your Medicare number
to verify your plan. Do not do that. Medicare number

(19:00):
is just like your Social Security So here's the truth.
Medicare doesn't sell plans or cold call. No one's supposed
to be cold calling you to offer you a Medicare
advantage plan without your permission. So even that in that case,
compliance wise, they're not supposed to do that. Only licensed

(19:23):
agents or brokers can legally discuss plan options. So yes,
there are volunteers that do this with ship, but license
independent insurance agents. They certify. We certify every single year
with Medicare, and every particular insurance company will work with.
And yes, be leary of those independent insurance agents that

(19:47):
only offer one plan or one company right, that to
me is just being a little bit lazy and not
certifying for other plan or insurance company options just because
you don't want to. Right, But not all sizes fits all.
Every senior is going to be different. So always guard

(20:10):
your Medicare card like you would your credit card or
your social If something doesn't feel right, hang up, call
Medicare directly when a hundred, Medicare your local trusted agent.
So the future of Medicare and what's expect looking ahead,

(20:30):
Medicare is moving toward a model of personalized preventive care.
We're seeing more emphasis on the chronic condition management, digital health,
and even home based care. And with home based care,
there is a difference like what is home based care
versus home healthcare versus being like in a skilled nursing right.

(20:53):
Home health is just when the provider comes, just make
sure everything's good. It's not going to like help you
with skilled nursing or caregiving support. That is going to
be different. So there is also a growing push for
the value based care model, meaning doctors are rewarded for

(21:15):
keeping you healthy, not just treating illness. So on your plans,
which pertains to the Medicare advantage plans, typically like you
get rewards. You get rewards for seeing your doctor at
a certain time of the year preventive care screenings, and
I think the doctor also gets bonuses, So definitely keep

(21:37):
that in mind. For seniors, that means more coordination and
less duplication and ideally better outcomes. I know sometimes insurance
companies do hire an outside vendor for a doctor to
come to your home to just kind of do a
second review. So just be careful, talk to us or
your licensed insurance advisor just to make sure because you

(22:00):
really don't want a scam in place. As well, the
key is really being staying informed because the rules, the costs,
the benefits continue to evolve. I mean, I'm hoping this
will definitely stabilize in a few years, but you know,
I don't have a crystal ball, So it is what

(22:25):
it is.

Speaker 1 (22:25):
On that.

Speaker 2 (22:31):
So, Medicare isn't just a government program. It's a living
system that changing right alongside of you. With change comes
opportunity to save money, improve your coverage, and take control
of your health. What we do here is very different

(22:51):
and unique. While most agents offer you a personalized Medicare
review or want to learn about upcoming changes that may
impact you, we definitely dig even deeper with plan comparisons
and guides doctor network alignments, just to make sure all
your doctors are still in the same network and that

(23:14):
you're on the right plan. So we're definitely here to
help you guide you through the way. I know right now,
many want to retire January first, so there's a lot
of movement, a lot of paperwork that needs to be
done to get this happening for you. I'm also seeing

(23:37):
a very very big increase in group health insurance. So
constantly companies are trying to cut back, trying to cut costs,
they're changing their insurance plans, or they're just charging way
more in your health coverage. So that is something to

(23:58):
see if Medicare might be a better opportunity for you.
So definitely, if you'd like that personalized Medicare review, want
to learn more about the upcoming changes that might impact you,
reach out to my team at Premiere three sixty Insurance
and Financial Solutions. We're here to help you to compare plans,

(24:21):
avoid penalties, and make confident decisions about your healthcare and coverage.
Visit us at Premier three sixty solutions dot com call
our office to schedule your free Medicare three sixty consultation.
So I'm Jennifer Alfonso Lee and this has been Medicare
three sixty Radio Show, your trusted voice for clear, practical

(24:43):
Medicare guidance. Until next time, stay healthy, stay informed, and
stayed empowered.

Speaker 1 (24:51):
Thank you for joining the program Medicare at three sixty.
I hope you found today's episode insightful and empowering. Remember,
understanding your Medicare options is key to making the right
choices for your health and financial well being. If you
have questions or topics that you would like covered on
future episodes of Medicare three sixty, don't hesitate to reach

(25:16):
out until next time. Stay informed and take charge of
your healthcare journey. This has been Medicare three sixty, your
trusted source for all things Medicare. Take care,