2025 Medicare Open Enrollment and ACA Enrollment: What You Need to Know

It’s that time of year again—Medicare Open Enrollment and ACA enrollment. However, this year, there are significant changes for 2025 that you should be aware of. Whether you’re currently on Medicare or planning to enroll, it’s important to take note of the updates.

You can watch the webinar I hosted earlier this month, which includes a Q&A session with blood cancer patients and caregivers, or continue reading below for more details. 

Watch the Webinar

Review Your Coverage for 2025

If you’re currently on Medicare, make sure to review your “Evidence of Coverage” (EOC) and “Annual Notice of Change” (ANOC) documents, which were mailed to you in September. Just because your insurance has worked well for you in the past doesn’t mean it will continue to do so without changes. Plans can alter their formularies and tiers, moving medications around, which may result in higher out-of-pocket costs or loss of coverage for certain drugs.

Here are a few key points to keep in mind:

• A medication that was affordable may now be more expensive.

• A drug that was previously covered might no longer be covered.

• Forward-thinking is crucial: Ask your doctor about upcoming changes to your prescriptions or treatment plans, so you can adjust your coverage accordingly.

• Mistakes in Medicare choices can be costly, so double-check everything before making decisions.

If your plan isn’t changing and your coverage meets your needs, no action is required. However, if you want to make changes, now is the time to do so.

Key Dates for Medicare Open Enrollment

• Open Enrollment Period: October 17 - December 7, 2024

• Changes Take Effect: January 1, 2025

During this period, you can:

• Review and change your Medicare Advantage Plan.

• Switch back to Original Medicare (Parts A & B).

• Update your prescription drug coverage.

• Enroll in a Medicare Advantage Plan if you’re currently on Original Medicare.

Part D Changes and Cost Caps

One of the most notable changes for 2025 is the new cap on out-of-pocket costs for Medicare Part D. Thanks to the Inflation Reduction Act, once you hit your maximum out-of-pocket limit, the cost of your covered Part D prescriptions will be zero for the rest of the year. It’s important to note this only applies to Part D prescriptions, not Part B drugs.

Key Changes to Part D for 2025:

• Maximum out-of-pocket costs for Part D will be capped at $2,000 (may increase yearly).

• You can choose to spread these out-of-pocket costs over the year by enrolling in a special payment plan.

• Part D plans will cover 65% of brand-name drug costs, while manufacturers will offer a 10% discount on brand-name drugs.

Medicare Enrollment Periods

Medicare has specific enrollment periods throughout the year, allowing you to apply for or change plans. Here are the main ones:

1. Initial Enrollment Period – For those enrolling in Medicare Parts A & B for the first time.

2. Special Enrollment Period – Available from January 1 - March 31 for changes in Medicare Advantage Plans.

3. Medigap Enrollment – Medigap (Supplemental) Plans require enrollment in Parts A & B and have their own timeframes for switching or enrolling in plans.

For more detailed information on Medicare Advantage, Medigap, and Part D enrollment periods, visit the Medicare Enrollment Periods Guide.

Understanding Medicare Part D Drug Coverage

Part D plans must cover at least two drugs per category, but each plan can choose which drugs to cover, so it's essential to review your plan every year. There are six protected classes of drugs that Part D plans must cover:

• Immunosuppressants

• Antidepressants

• Antipsychotics

• Anticonvulsants

• Antiretrovirals

• Antineoplastics

If you’re enrolled in a Medicare Advantage Plan, you can make changes during the Special Enrollment Period from January 1 - March 31. If your plan is ending, you will be automatically enrolled in a new one, but you have until the end of February to make any changes.

Medigap Plans

• You need Medicare Parts A and B to qualify for a Medigap plan.

• Enroll when you’re first eligible to benefit from guaranteed issue rights (your medical history won’t affect approval).

• Medigap plans help cover gaps in Traditional Medicare, like copays and coinsurance, and you can enroll at any time during the year.

Help for Lower-Income Enrollees

If your income is on the lower end, you may qualify for assistance to help cover Medicare premiums. Programs like Extra Help can offer financial relief. Visit Medicare.gov or the Social Security Administration (SSA) to see if you qualify.

For one-on-one help, contact your local State Health Insurance Assistance Program (SHIP) by visiting ShipHelp.org or calling 1-877-839-2675.

Action Steps

The changes coming to Medicare for 2025 are more substantial than in previous years. Review your plan summary carefully to understand what’s changing for you and take action as needed to ensure you have the best coverage for your health and financial needs.

To check your eligibility and explore assistance programs like Extra Help, visit:

• SSA Extra Help Program

• Call SSA at 1-800-772-1213 for assistance.