MEDICARE DRUG PLANS AND MORE FOR 2023: GOOD NEWS AND NOT AS GOOD NEWS

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Posted on October 12, 2022 by thehealthinsuranceanswerman

By D. Kenton Henry editor, agent, broker 12 October 2022

In a year in which the annual inflation rate is over 9%, and the core inflation rate over 6%, there is some good news relative to Medicare Part D 2023 Drugs and Plan costs. And it comes just in time as the approximately 64 million Americans on Medicare will be electing their drug coverage during the “Annual Election Period” from October 15th through December 7th, for coverage to begin January 1.

While Medicare Part A (hospital and skilled nursing facility) coverage has been paid for during the working careers of most Americans or their spouses, Part B (out-patient coverage) has not. Medicare accesses an income-adjusted monthly premium based on a “two-year look-back at one’s income tax return. (for details refer to Chart 1, and Feature Article 1, below)

The base premium for individuals earning $97,000 or less, and couples filing jointly earning $194,00 or less, will be down $5.20 per month from $170.10 to $164.90. The Medicare Part B out-patient deductible will be down $7.00 from $233.00 to $226.00 in 2023. Although these decreases are nominal, to say the least, they are a move in the right direction.

The “not as good news” is that Part A Inpatient hospital costs to the beneficiary will be increasing. The inpatient hospital deductible is going to $1,600 for each admission – due to a different medical condition – or the same medical condition separated by 60 days or more. And the daily coinsurance for days 61-90 is going to $400 and for lifetime reserve days to $800. It is easy to see that most can ill afford to be liable for the cost of an extended hospital stay without supplemental coverage, such as Medicare Supplement or Medicare Advantage, to pay these expenses. (for details, refer to Chart 2 below)

Relative to Medicare Part D Prescription Drug Plans, the headline subject of this article, the best news is probably not that premiums are actually decreasing for many of the approximately 30 plan options available. Surveys show that Americans are more concerned about the price of their drugs than their plan premiums. So, more good news is that the cost of insulin – which has historically created something of a hardship for dependent diabetic patients – will be limited to a $35.00 monthly cap on insulin copays for Part D enrollees. In addition, all vaccines recommended for adults by the CDC will be available at no cost.

If not reversed, even greater cost savings are scheduled for 2024 and beyond. Here are some of the highlights:

2024

i) Part D enrollees entering the “catastrophic” phase of coverage will not owe any additional copays for the year. In other words, they will have 100% coverage.

ii) Part D premiums will be capped at a maximum price increase of 6% annually through 2029. Additionally, the government will expand eligibility for financial assistance.

2025

i) Out-of-pocket Medicare drug costs will be capped at $2,000 each year.

ii) Additionally, Part D enrollees will be able to spread out copay costs over the entire year, preventing hardship created by extremely high one-time bills.

2026

This will be the first year Medicare will be permitted to negotiate the cost of drugs. This will be limited to 10 drugs in 2026, increasing to 60 drugs by 2029.

These proposed changes all sound encouraging. Let us hope they survive to fruition. In the meantime, it is my job to assist my clients, and prospective clients, in identifying their lowest “total” cost Part D Drug plan for each calendar year. While people get fixated with monthly premium, one’s lowest total cost is the sum of their plan’s premium + any deductible due before their drugs become available for copays or coinsurance + their copays or coinsurance. We are seeking the lowest sum. It can be a tedious and confusing task for many and I assume that task for any client or prospective client requesting assistance.

For 2023 plan marketing, Medicare mandates I post the following disclaimer:

While I offer most, “I do not offer every plan available in your area. Please contact Medicare.gov or call 1-800-MEDICARE to get information on all your options.”

That being dispensed with, permit me to add – When someone requests I research the market for their lowest “total” cost drug or Medicare Advantage Plan, I not only employ proprietary software, but I utilize Medicare’s own data to make my recommendation. So rest assured, I have thoroughly reviewed all their options in the market before making my recommendation.

I do not charge a fee for my services. If you do not take advantage of my recommendation, you are out of nothing but the time we have spent together in arriving at it. However, if I introduce you to an insurance product, and you elect to apply for it, I only hope you will go through me to do so. You are not obligated to. Then, and only then, will I be compensated directly by the insurance company whose product you elect. The key to you is – you will pay no more premium for that product than if you were to walk in the front door of that company and purchase it directly from them. All companies in the Medicare Part D and Medicare Advantage market pay me the same so my objectivity is assured. Therefore, I like to think, you gain all the expertise my 36 years in the industry has to offer you at no additional charge. This is as opposed to a different person each time at the end of a toll-free number. I encourage you to take advantage of my offer and I look forward to establishing a working relationship with you.

D. Kenton Henry

All Plan Med Quote

Https://TheWoodlandsTXHealthInsurance.com Https://Allplanhealthinsurance.com Https://HealthandMedicareInsurance.com Office: 281-367-6565 Text my cell 24/7 @ 713-907-7984

d. kenton henry, Health insurance, kenton henry medplus messenger administrator, Medicare, Medicare Advantage, medicare part d, Patient Protection and Affordable Care Act, thewoodlandstxhealthinsurance.com

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CHART 1

Full Part B Coverage
Beneficiaries who file individual tax returns with modified adjusted gross income:	Beneficiaries who file joint tax returns with modified adjusted gross income:	Income-Related Monthly Adjustment Amount	Total Monthly Premium Amount
Less than or equal to $97,000	Less than or equal to $194,000	$0.00	$164.90
Greater than $97,000 and less than or equal to $123,000	Greater than $194,000 and less than or equal to $246,000	$65.90	$230.80
Greater than $123,000 and less than or equal to $153,000	Greater than $246,000 and less than or equal to $306,000	$164.80	$329.70
Greater than $153,000 and less than or equal to $183,000	Greater than $306,000 and less than or equal to $366,000	$263.70	$428.60
Greater than $183,000 and less than $500,000	Greater than $366,000 and less than $750,000	$362.60	$527.50
Greater than or equal to $500,000	Greater than or equal to $750,000	$395.60	$560.50

CHART 2

Part A Deductible and Coinsurance Amounts for Calendar Years 2022 and 2023 by Type of Cost Sharing
	2022	2023
Inpatient hospital deductible	$1,556	$1,600
Daily coinsurance for 61^st-90^th Day	$389	$400
Daily coinsurance for lifetime reserve days	$778	$800

*******************************************************************

FEATURE ARTICLE 1

CMS: Medicare Part B Premiums, Deductibles Will Decrease in 2023

Monthly Medicare Part B premiums will fall to $164.90 in 2023, marking a $5.20 decrease from this year, while Part A premiums are set to increase by $4 to $7.

Source: CMS Logo

By Victoria Bailey

September 27, 2022 – Medicare Part B premiums and deductibles will decrease in 2023, while Part A costs will rise, according to a fact sheet released by CMS.

Medicare Part B offers coverage for physician services, outpatient hospital services, certain home healthcare services, durable medical equipment (DME), and other medical services not covered by Medicare Part A.

The standard monthly premium for Part B enrollees will be $164.90 compared to $170.10 in 2022. The annual deductible will be $226, decreasing $7 from $233 in 2022.

Dig Deeper

The 2022 premiums included a contingency margin for projected Part B spending on the Alzheimer’s disease drug Aduhelm. However, 2022 saw lower-than-expected spending on Aduhelm and other Part B services, leading to larger reserves in the Part B account of the Supplementary Medical Insurance (SMI) Trust Fund. This trust fund helps limit Part B premium increases, resulting in lower premiums for 2023.

Individuals with Medicare who take insulin through a pump supplied through the Part B DME benefit will not have to pay a deductible starting on July 1, 2023. In addition, cost-sharing will be capped at $35 for a one-month supply of covered insulin.

In 2023, Medicare beneficiaries who are 36 months post-kidney transplant can choose to continue Part B coverage of immunosuppressive drugs despite no longer being eligible for full Medicare coverage. These individuals will have to pay a monthly premium of $97.10 for immunosuppressive drug coverage.

Medicare beneficiaries with incomes greater than $97,000 will have higher Part B premiums. For example, monthly premiums will range from $230.80 to $560.50 for high-income beneficiaries. Similarly, monthly immunosuppressive drug coverage premiums will vary from $161.80 to $485.50 for high-income beneficiaries.

The While Part B costs will decrease in 2023, Part A costs are set to increase.

Medicare Part A offers coverage for inpatient hospital services, skilled nursing facility care, hospice care, inpatient rehab, and home healthcare services.

The Medicare Part A inpatient hospital deductible for beneficiaries admitted to the hospital will be $1,600 in 2023, rising from $1,556 in 2022. This deductible covers beneficiaries’ share of costs for the first 60 days of inpatient hospital care.

For days 61 through 90 of hospitalization, beneficiaries will have to pay a coinsurance amount of $400 per day, up from $389 in 2022. Past 90 days, the coinsurance will rise to $800 per day. The daily coinsurance for individuals in skilled nursing facilities will be $200 for days 21 through 100 of extended care services, up from $194.50 in 2022.

The majority of Medicare beneficiaries do not have to pay a Part A premium because they have worked at least 40 quarters in their life, the fact sheet noted. However, for those who have not, 2023 premiums are increasing.

Individuals who have at least 30 quarters of coverage or were married to someone with at least 30 quarters of coverage will have a Part A monthly premium of $278 in 2023, compared to $274 in 2022.

Individuals with less than 30 quarters and those with disabilities will have to pay the full 2023 premium of $506 per month, which is $7 higher than in 2022.

The fact sheet also shared 2023 information on Medicare Part D costs. Premiums for Medicare Part D, which offers drug coverage, vary from plan to plan. Around two-thirds of beneficiaries pay premiums directly to their plan, while the other third have their premiums deducted from their Social Security benefit checks.

Beneficiaries with incomes above $97,000 must also pay an income-related monthly adjustment amount in addition to their Part D premium. The amounts will range from $12.20 to $76.40 for high-income beneficiaries.

*******************************************************************

FEATURE ARTICLE 2

6 Policies To Reduce Prescription Drug Prices, Boost Competition

As prescription drug spending climbs, ACHP is calling on policymakers to reduce high prescription drug prices and enhance market competition.

By Victoria Bailey

September 02, 2021 – The Alliance of Community Health Plans (ACHP) is urging the federal government to take action and lower prescription drug prices with a set of recommended actions.

The costs of prescription drugs continue to rise each year, but policymakers have done little to address it. ACHP’s list of suggestions ranges from increasing drug pricing transparency to expanding the use of biosimilars.

Catastrophic Medicare Part D prescription drug spending has been on the rise for over a decade. Seniors do not have an out-of-pocket cap for Medicare Part D, which can leave them with high costs in the catastrophic phase.

Dig Deeper

ACHP’s first recommendation is to redesign the Medicare Part D benefit including creating an out-of-pocket healthcare spending cap for seniors and to ensure that consumers will not owe anything during the catastrophic phase. Drug companies should also have to assume financial responsibility for each Part D phase and take some of the pressure off of Medicare.

Medicare should also receive resources to allow the program to negotiate lower drug prices for their beneficiaries, ACHP suggested.

ACHP’s next recommendation was for the federal government to allow the US Department of Health and Human Services (HHS) to negotiate prices for expensive prescription drugs that have no generic or biosimilar competition. These drugs were responsible for 60 percent of Part D spending in 2019, the fact sheet noted.

Currently, HHS has no power over competitive drug pricing.

Policymakers should also extend price negotiation to the commercial market to keep drug companies from shifting costs to non-Medicare consumers.

High-cost drugs that face no competition should also have an International Pricing Index applied that will limit the price to no more than 120 percent of its average international market price. The previous administration supported a similar approach through its Most Favored Nation model, but the Biden administration has proposed to rescind that model.

ACHP also urged the federal government to increase the use of biosimilars by informing clinicians and patients of the products and by persuading the Federal Trade Commission to increase biosimilar presence on the drug market. There are 29 FDA-approved biosimilars that are more affordable than other prescription drugs, but less than 12 are available on the market.

Increasing reimbursement rates for biosimilars could also improve utilization, the fact sheet stated.

ACHP’s suggestions also targeted drug companies’ unjustifiable raising of drug prices. At the beginning of 2021, 735 drugs prices increased up to 10 percent without reason.

Prescription drug prices often increase faster than the inflation rate, therefore ACHP recommended that drug manufacturers should have to provide rebates for drug price increase above the inflation rate.

Drug companies should also have to follow a price transparency rule that would require manufacturers to report and justify price increases, ACHP stated.

One example is the FAIR Drug Pricing Act, introduced in the Senate in 2019 and referred to the Committee on Health, Education, Labor, and Pensions. This Act would require drug manufacturers to notify HHS and submit a transparency and justification report 30 days before increasing the price of certain drugs by more than 10 percent.

Lastly, the ACHP recommended that the federal government encourage the use of transparent fee-based pharmacy benefit managers (PBMs). Traditional PBMs are typically not transparent about rebates, which can encourage high-cost drug use, whereas transparent fee-based PBMs pass rebates and discounts onto payers and earn revenue through a clear administrative fee.

Payer organizations have turned to the federal government to get prescription drug prices under control, as pharmaceutical companies are not budging.

In January 2021, AHIP called on the Biden Administration to focus on solutions that would protect Americans from higher drug prices.

The issue is pressing, not only for the seniors on whom some of ACHP’s recommendations focused but for all Americans. AHIP reported that the highest portion of commercial health insurance premiums goes toward prescription drug costs, making prescription drug pricing a widespread concern.

DENTAL INSURANCE – IS IT REALLY WORTH WHAT I PAY FOR IT OR JUST A TIME PAYMENT PLAN?

Posted on April 7, 2026 by thehealthinsuranceanswerman

By D. Kenton Henry – editor, agent, broker

Dental Insurance: Worth the Premium — or Just a Payment Plan?

“Is dental insurance really worth what I pay for it?”

That’s a question I hear often—and it’s usually followed by:

“Or am I just spreading the cost of my dental work over time?”

My answer?
It depends—but it doesn’t have to be a losing proposition.

Employer vs. Individual Coverage

If you receive dental insurance through an employer, part (or all) of your premium is subsidized. That makes the value proposition much more favorable.

However, if you are:

Self-employed
Retired
Or purchasing coverage on your own

…then you’re paying the full premium—and the math becomes more important.

Without the right strategy, dental insurance can become nothing more than a time-payment plan. Worse yet, you could end up paying more in premiums than you ever receive in benefits.

The Reality of Dental Costs

Let’s be honest—dental work is expensive.

A single dental implant can cost anywhere from $3,500 to $7,000. And unlike medical insurance, dental plans come with strict limitations.

Before choosing a plan, there are three key concepts you need to understand:

1. “Reasonable and Customary” Limits

No insurance company pays unlimited fees.

Instead, they base payments on what is considered “reasonable and customary” for your geographic area.

A crown in Beverly Hills will cost more than one in Brenham, Texas
If a dentist charges above the accepted range, you pay the difference

Understanding this concept is critical to avoiding unexpected costs.

2. Network vs. Non-Network Plans

Dental plans fall into two categories:

Network Plans (Recommended)

PPO (DPPO): Flexibility to go out-of-network (at higher cost)
HMO (DHMO): Must stay in-network for coverage

These plans offer lower negotiated fees because dentists agree to discounted rates.

Non-Network Plans

“Any dentist” plans
Typically higher premiums
Often result in higher out-of-pocket costs

Why? Because dentists are free to charge above what the insurance company considers reasonable—and you’re responsible for the difference.

3. The Most Important Rule: Avoid Excess Charges

Here’s where many people get burned:

With a non-network plan, you can be billed above what insurance pays
With a network plan, dentists must write off excess charges

That means:

If your share is 20% or 50%—that’s all you pay. No surprises.

Finding the Right Dentist (and Plan)

As an individual, you don’t have the bargaining power of a large employer.

So how do you gain access to lower fees and quality care?

You choose an insurance company that:

Has a large, reputable network
Pays claims promptly and reliably
Attracts high-quality dentists

Then you select a dentist based on:

Credentials
Technology used
Patient reviews
Location and convenience

Understanding Benefit Limits

Dental insurance is not unlimited coverage.

Typical plans:

Cover $1,000–$1,500 per year
Higher-end plans may go up to $5,000 annually
Often include waiting periods for major work

A smarter strategy is to choose a plan that:

Starts affordable
Increases benefits over time
Aligns with your expected dental needs

A Real-World Strategy (From Experience)

After decades in the business—and personal experience with extensive dental work—I approached my own coverage strategically.

I selected:

A financially strong insurance company
A plan that started at $1,500, then increased to $2,500, and ultimately $5,000 annually
A highly qualified dentist within the network

This allowed me to:

Stage treatment over time
Maximize benefits
Avoid excessive out-of-pocket costs

Bottom Line: How to Make Dental Insurance Work

To get real value from dental insurance:

✔ Choose a network plan

✔ Match benefits to your expected needs

✔ Select a skilled, in-network dentist

✔ Work with a knowledgeable advisor

How I Can Help

With over 30 years of experience in health, Medicare, and dental insurance, I help clients:

Compare plans from top-rated carriers
Avoid costly mistakes
Maximize benefits relative to premium

I represent companies such as:
Aetna, Ameritas, Anthem, Blue Cross Blue Shield, Cigna, Delta Dental, Humana, and UnitedHealthcare.

Let’s Talk

If you’re considering dental coverage—or wondering if your current plan is worth it—I’d be happy to help.

D.Kenton Henry

TheWoodlandsTXHealthInsurance.com
📞 281-367-6565
Text my cell 24/7 @ 713-907-7984

Final Thought

Dental insurance can either be:

A smart financial tool
or
An expensive payment plan

The difference lies in how you choose—and how you use—it.

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News Flash: Indiana Medicare Supplement “Birthday Rule” Expanded! (Good news for Hoosier Medicare Supplement policyholders)

Posted on March 12, 2026 by thehealthinsuranceanswerman

By D. Kenton Henry – editor, agent, broker
12 March 2026

Good news for Indiana Medicare Supplement policyholders.

A recent update to Indiana’s new Medicare Supplement Birthday Rule has expanded the period during which eligible individuals may change their Medigap coverage without medical underwriting.

This change may reopen opportunities for some individuals who believed they had already missed their window.

HOT OFF THE PRESS

What Changed?

Beginning March 15, 2026, the Birthday Rule now allows policyholders to apply for a replacement Medicare Supplement policy during a period that begins:

31 days before their birthday and continues through 31 days after their birthday.

This creates a 63-day annual window centered around a person’s birthday.

What This Means

If you currently have a Medicare Supplement (Medigap) policy, you may now apply during this window to switch to the same plan letter offered by a different insurance company.

The insurance company must approve the application regardless of health conditions, provided the rule’s requirements are met.

Example

If your birthday is March 4, your Birthday Rule window would run from approximately:

February 1 through April 4

This means individuals with March birthdays who thought they missed the opportunity earlier this year may still qualify to apply.

Important Requirements

To use Indiana’s Birthday Rule:

• You must currently have a Medicare Supplement policy
• The new policy must be the same plan letter as your current coverage
• The application must be submitted within the 31 days before or after your birthday
• The new policy will take effect on the first day of the month following the application date

Your broker will also need documentation confirming your current plan letter.

Why This Matters

For many seniors, this rule creates an opportunity to:

• Review Medicare Supplement premiums
• Change insurance companies
• Potentially lower monthly costs

— without answering health questions or risking denial of coverage.

Need Help Reviewing Your Options?

If your birthday falls within this window and you would like to see whether switching carriers might benefit you, I would be happy to help review your options.

D. Kenton Henry
Office: 281-3676565
Text my cell 24/7 @713-907-7984
Email: Allplanhealthinsurance.com

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NEW INDIANA MEDICARE SUPPLEMENT “BIRTHDAY RULE” NOW IN EFFECT

Posted on March 4, 2026 by thehealthinsuranceanswerman

a New Opportunity to Change Your Medicare Supplement Plan Without Health Questions

By D. Kenton Henry – editor, agent, broker

Dear Hoosier Clients and Friends,

Beginning January 1 of this year, Indiana implemented a new consumer protection commonly called the Medicare Supplement Birthday Rule. This new law provides Medicare beneficiaries with an important opportunity each year to change their Medicare Supplement (Medigap) plan without medical underwriting.

For many people, this means you may now be able to replace your current Medicare Supplement policy with a similar or lower-benefit plan and be guaranteed acceptance, regardless of health conditions.

What the Indiana Birthday Rule Allows

Under the new rule, eligible Indiana residents may apply for a replacement Medicare Supplement policy each year around their birthday, and the insurance company must approve the application if the required conditions are met.

This protection is intended to give policyholders a way to review and potentially reduce premiums while maintaining Medicare Supplement coverage.

Key Requirements to Qualify

To take advantage of Indiana’s Birthday Rule, the following conditions must be met:

1. You Must Currently Have a Medicare Supplement Policy

The rule applies only to individuals who are already enrolled in a Medicare Supplement (Medigap) plan.

2. You Must Be Replacing Your Plan With the Same or Lower Benefits

You may switch to another Medicare Supplement plan that offers equal or lesser benefits than your current policy.
For example:

Plan G → another company’s Plan G
Plan G → Plan N
Plan F → Plan G

However, you cannot move to a plan with richer benefits under the Birthday Rule.

3. You Must Apply at Least 60 Days Before Your Birthday

Under Indiana’s new rule, the application signed and received date must be within 60 days from the applicant’s birthday. And the effective date must be on the first day of the month that is at least thirty (30) days after the signature date.

The replacement policy will become effective on the first day of your birthday month.

Medical Underwriting Is Waived

If the above conditions are met, the insurance company cannot deny your application due to health conditions.

Why This Rule Matters

Before this rule took effect, Medicare Supplement policyholders often had to undergo medical underwriting to change plans. That meant individuals with health conditions could be:

Declined for coverage
Charged higher premiums
Unable to change carriers

The Birthday Rule now provides an annual opportunity to review your coverage and potentially reduce premiums without having to answer health questions.

Should You Review Your Plan?

Even if you are satisfied with your current Medicare Supplement coverage, it may still be worthwhile to review your options. Insurance companies frequently adjust their pricing, and another carrier may offer the same plan benefits at a lower monthly premium.

The Birthday Rule allows you to explore those options without risking your coverage.

I Am Here to Help

If your current agent has not informed you of this opportunity, ask yourself, “Why?”

If your birthday is approaching and you would like to review your Medicare Supplement options under Indiana’s new Birthday Rule, please contact our office. I can help determine whether changing plans could benefit you.

Thank you for allowing me to continue assisting you with your Medicare coverage.

Sincerely,

D. Kenton Henry
Office: 281.367.6565
Text my cell 24/7 @ 713.907.7984
Email: Allplanhealthinsurance.com@gmail.com
Https://HealthandMedicareInsurance.com

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2026 ACA Subsidies: What’s Happening With Advance Premium Tax Credits?

Posted on December 8, 2025 by thehealthinsuranceanswerman

(What Consumers Need to Know for the 2026 Marketplace)

D. Kenton Henry – editor, agent, broker

As we approach the 2026 plan year, one of the biggest questions in individual and family health insurance is what will happen to Advance Premium Tax Credits (APTCs)—the subsidies that lower monthly premiums for millions of Marketplace enrollees.

Why This Is Happening

During the COVID era, Congress passed temporary legislation — most recently extended under the Inflation Reduction Act (IRA) — which made Marketplace subsidies more generous and available to more households. These enhanced subsidies are scheduled to expire at the end of 2025, unless Congress acts to extend them.

If they expire, the Marketplace will revert to pre-COVID subsidy rules, which means:

1. Lower income thresholds for subsidy eligibility

Some households who qualified for subsidies under the temporary rules will no longer qualify at all.

2. Smaller subsidies for many who remain eligible

People who received very large subsidies during 2021–2025 would see higher net premiums for 2026, even if their income has not changed.

3. The return of the “subsidy cliff”

Under pre-COVID rules, households with income even slightly above 400% of the Federal Poverty Level received no subsidy. The COVID-era rules removed that cliff. If not renewed, the cliff returns.

This is why some people are seeing early projections showing their 2026 premiums rising sharply.

Where Things Stand in Congress

Both parties publicly acknowledge that the expiration would lead to large premium increases for many families. As of today:

There is broad interest in finding a solution, but
No final legislation has been passed,
No guarantee exists that the enhanced subsidies will continue, and
Any resolution will likely be tied to larger budget negotiations.

In short: Congress is still debating it, and the outcome directly affects what consumers will pay for Marketplace coverage in 2026.

What Consumers Should Expect

Until Congress acts, the Marketplace must begin preparing 2026 rates under the assumption that the enhanced subsidies expire. This means:

Preliminary quotes may show dramatically higher net premiums
Some currently subsidized families may temporarily appear ineligible for assistance
Final 2026 subsidy amounts cannot be known until legislation is passed — if it is passed

It is important to remember that this may change, depending on Congressional action in the coming months.

Practical Guidance for Individuals and Families

Don’t panic if early projections show large increases.
Stay informed — subsidy rules may be extended or modified.
Review your 2026 options with a licensed, experienced broker who can calculate subsidies under both scenarios.
Update income estimates accurately during Open Enrollment; small changes can affect substantial tax credit differences.

Bottom Line

The enhanced ACA subsidies that helped make Marketplace coverage more affordable since 2021 are set to expire after 2025, and Congress has not yet determined whether they will be renewed. Until a resolution is reached, 2026 Marketplace premiums may appear significantly higher for many Americans.

I will continue to monitor developments closely and provide updates as soon as new information becomes available.

Additionally—

It has come to my attention that my clients have been told the First Health PPO network plan is being mistakenly interpreted by them as being an Affordable Care Act (ACA) compliant PPO network. As such, they incorrectly believe any and all of their pre-existing health conditions will be covered and that all preventive exams and medicine will be covered at no out-of-pocket cost to them. This is wrong and here is the truth, as confirmed by me and ChatGPT:

✅ 1. There are no ACA-compliant PPO plans available in Texas individual/family (On- or Off-Exchange)

Texas has not had a true ACA-compliant individual market PPO option for several years.
All carriers (BCBSTX, Ambetter, United/Optum, Aetna CVS, Oscar, Cigna, Moda, etc.) offer only:

EPOs
HMOs

These networks limit out-of-network benefits and require referrals or tighter network management.

A PPO requires:

National or multi-state contracted provider access
True out-of-network benefits
No referral requirement

No carrier has offered this in the ACA individual Texas market since around 2017–2018.

✅ 2. Aetna is not selling ACA individual/family plans in Texas for 2026 (and has already exited)

Your clients may be confused because Aetna offers:

Medicare Advantage PPOs
Employer-based PPOs
First Health networks tied to group/other products

But Aetna does NOT offer ACA individual/family plans in Texas for 2026.

So if someone believes they have an “Aetna PPO” under an ACA plan, they are mistaken. It is either not an ACA plan, or they are misinterpreting the network type.

✅ 3. If their plan is marketed as “PPO-like,” it is almost certainly:

a) A short-term medical plan

These frequently use PPO networks—including Aetna’s First Health—but they are:

NOT ACA-compliant
Do NOT cover pre-existing conditions
Can cap benefits
Can deny claims based on underwriting

b) A health-sharing ministry

Often marketed as “PPO plans” because they use rented networks, but also:

Not insurance
Not regulated as insurance
No claim guarantees
No ACA protections

c) A fixed-benefit plan that uses First Health or MultiPlan PPO

Again:

Not insurance
No ACA protections
No out-of-pocket maximums
No guaranteed coverage

d) A direct primary care + medical indemnity bundle

These are sometimes misrepresented as “PPO plans,” but they are not.

✅ 4. How to confirm instantly whether the client is on ACA-compliant coverage

Ask for one of the following:

A) The name of the carrier.

If it’s not:

BCBSTX
Cigna
Ambetter
UnitedHealthcare (UHC Marketplace)
Aetna CVS (in some states, but NOT Texas 2026)
Moda
Oscar (until exit)

…then it’s almost certainly not ACA-compliant.

B) A copy of the Summary of Benefits & Coverage (SBC).

All ACA plans must include an SBC — short-term plans and sharing ministries do not.

C) Their monthly bill or ID card.

If it says things like:

First Health Network
MultiPlan PPO
PHCS PPO
Aetna PPO
United Healthcare Choice/Choice Plus PPO

…that is almost certainly a non-ACA plan.

✅ 5. Bottom line for you:

If you believe you they are on an ACA-compliant “Aetna PPO” for individual/family coverage:

You are not. No such product exists in the Texas ACA market. You are almost certainly on a short-term plan, health-sharing product, or fixed-benefit plan using a rented PPO network.

This is an excellent opportunity for ne to help you transition to true ACA coverage, where you will regain:

Pre-existing condition protection
Essential health benefits
No annual/lifetime caps

And – perhaps most importantly – Out-of-pocket maximum protection

Please feel free to call me with any questions you may have or for assistance in obtaining 2026 ACA compliant health insurance. I will make the quoting and application process go as quickly and smoothly as possible whether you quailify for a subsidy or not.

The Open Enrollment Period for a January 1 effective date ends December 15th. You have until January 15th to obtain an effective date of February 1.

D. Kenton Henry
Office: 281-367-6565
Text my cell 24/7@ 713-907-7984
Email: Allplanhealthinsurance.com@gmail.com

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What Texas Consumers Must Know as the 2026 Individual & Family Health Insurance Market Evolves

Posted on October 30, 2025 by thehealthinsuranceanswerman

By D. Kenton Henry, Editor / Agent / Broker — TheWoodlandsTXHealthInsurance.com, AllPlanHealthInsurance.com, HealthandMedicareInsurance.com 30 October 2025

Each November in Texas marks more than just the start of the new health insurance year—it’s your gateway to securing coverage for the year ahead. This time around, the 2026 individual and family health insurance market is undergoing noticeable changes. Here’s what you need to know—and how you can be ready.

1. Why 2026 matters

Open enrollment for 2026 policies begins November 1, 2025, and runs until January 15, 2026 for most Texas consumers. If you don’t act in this window, you could be locked out of making changes until next year unless a qualifying life event occurs. Given major shifts among carriers and plan options, early action is more important than ever.

2. Carrier changes you should track

One of the major headlines: Aetna will exit the Texas individual and family market beginning in 2026. That means if you currently have an Aetna plan, your policy will not renew for 2026. You’ll need to select a different carrier in the upcoming enrollment period.

Other carriers are repositioning their offerings, adjusting networks, benefits, and rates. Even if your carrier is staying, plan names and design may change. As your broker, I’ll review all available options from multiple carriers and ensure you’re not simply renewing by default.

3. What this means for you

No automatic renewal: If your carrier exits the market, your current plan will not carry over. You’ll receive a Notice of Change—or termination—and need to select a new plan.
Shop your options: Differences between plans are not only about monthly premiums. Review networks, cost-sharing, deductibles, out-of-pocket maximums, and whether benefits match your healthcare needs.
Subsidy changes: The federal subsidy rules continue to evolve. Even small changes in income, household, or eligibility can shift your subsidy level. I’ll help you analyse eligibility for Advance Premium Tax Credits (APTC) and other cost-saving tools.
Timing matters: Beginning November 1, I’ll be available to assist you through the selection process—not just on carriers and plans, but on ensuring accurate enrollment to avoid coverage gaps.

4. Why working with a broker matters

As an independent broker specializing in medical insurance since 1986, I work with virtually every major carrier licensed in Texas. My services to you are free of charge. My goal is to ensure you get the best plan that fits your health needs, budget, and preferences—especially in a year of significant market change.
Rather than navigating dozens of plan names on your own, let me do the heavy lifting and help you make an informed choice.

5. What to do now

Gather your information – your current health plan, recent premium receipts, summary of benefits, and any health changes.
Schedule your review – open enrollment kicks off November 1. If you’d like early preparation, I’m available now to pre-review your situation so you’re ready to act.
Act during the window – November 1 through January 15 is your open period. Plans go into effect January 1, 2026, or, depending on carrier rules, as early as December 1, 2025.
Don’t wait – with carrier exits and plan redesigns in motion, the sooner you start the review, the better your chance of finding the optimal match.

Working together, we’ll turn these market shifts into an advantage—so instead of scrambling when notices arrive, you’ll move confidently into 2026 with coverage aligned to your needs. Let me handle the complexity so you can focus on your life, your health, and your goals.

If it’s after hours, or you simply prefer, you can do preliminary research before calling me by obtaining quotes from my quoting engine. You do NOT have to log in to obtain them but be certain to call me afterwards with questions, and assistance in finding your providers within the networks, as well as applying. CLICK HERE: https://allplaninsurance.insxcloud.com/get-a-quote

D. Kenton Henry

Editor · Agent · Broker
TheWoodlandsTXHealthInsurance.com * AllPlanHealthInsurance.com * HealthandMedicareInsurance.com

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KEY CHANGES TO MEDICARE PART D DRUG AND ADVANTAGE PLANS IN 2026

Posted on September 30, 2025 by thehealthinsuranceanswerman

D. Kenton Henry
Editor, agent, broker
30 SEPTEMBER 2025

Medicare 2026: Welcome clients and prospective clients! Before reading this (if you have not already), you should go to your mail box and retrieve your 2026 Annual Notice of Change from Medicare. You were due to receive it no later than today per Center For Medicare Rules and Regulations. If will give you a good idea if you need to re-shop your Medicare Advantage or Part D Drug plan for the coming calendar year. If not, the following changes may.

10 changes to review before the Annual Election period, often referred to as the Open Enrollment (Oct 15–Dec 7)

If you’re on Medicare, 2026 brings important updates—especially to prescription drug coverage. The Part D out-of-pocket cap rises to $2,100, the standard deductible becomes $615, and Medicare’s first negotiated drug prices start on January 1, 2026. Medicare Advantage also gets new guardrails around prior authorization and appeals, and some supplemental “perks” are being narrowed. Check your Annual Notice of Change (ANOC) (it should arrive by Sept 30) and compare your plan options—small differences can mean big savings. If you’d like help, I’ll review your medications, doctors, and benefits to make sure you’re in the right fit for January 1.

Here is an itemized list of the 10 Key Changes:

Medicare changes your 2026 plan review should cover

1) Part D’s annual out-of-pocket cap rises to $2,100.
Once a member’s 2026 Part D out-of-pocket spending reaches $2,100, they’ll pay $0 for covered Part D drugs for the rest of the calendar year.

2) The standard Part D deductible increases to $615.
Plans can’t set a deductible higher than $615 in 2026 under the redesigned Part D rules.

3) Drug price negotiations start showing up at the counter.
Medicare’s first set of negotiated Maximum Fair Prices (MFPs) for 10 widely used Part D drugs take effect January 1, 2026. Members should review their ANOC and plan formularies to determine how these prices impact their medications.

4) Insulin and adult vaccines: protections continue.
Part D insulin remains capped and no-deductible; starting in 2026, the cap is the lesser of $35, 25% of the MFP, or 25% of the negotiated price. ACIP-recommended adult vaccines remain $0 under Part D.

5) “Pay-over-time” for prescriptions auto-renews.
The Medicare Prescription Payment Plan (monthly billing instead of paying large amounts at the pharmacy) auto-renews in 2026 unless the member opts out. It smooths payments but doesn’t lower total costs—good to remind clients who tried it in 2025.

6) Medicare Advantage prior-auth and appeals guardrails tighten.
For 2026, CMS says MA plans must honor previously approved inpatient admissions (can only reopen for obvious error or fraud), and CMS closes appeals loopholes so members and providers receive required notices and can appeal adverse coverage decisions. Expect fewer mid-stay reversals. Centers for Medicare & Medicaid Services

7) Limits on certain “extra perks” in MA (SSBCI) take effect.
CMS codified non-allowable Special Supplemental Benefits for the Chronically Ill—examples include non-healthy food, alcohol, tobacco, and life insurance. Some plans may rebalance extras as a result.

8) Star Ratings update: new/returning measures.
2026 Stars add or reintroduce measures like Kidney Health Evaluation for Patients with Diabetes plus Improving/Maintaining Physical and Mental Health (weight = 1). Tougher cut points in 2026 may shift plan bonuses and benefit richness—worth watching locally.

9) Part D benefit design shifts behind the scenes.
Liability shares change across phases (plans, manufacturers, CMS), and there’s a new subsidy for selected (negotiated) drugs. Members may see formulary/tier adjustments—another reason to compare plans.

10) ANOC timing: what to tell clients.
Remind everyone: Annual Notice of Change (ANOC) letters arrive by September 30 each year; if they didn’t see one, call the plan. Open Enrollment runs Oct 15 – Dec 7 for Jan 1 effective dates.

Check your Annual Notice of Change (ANOC) (it should arrive by Sept 30) and compare your plan options—small differences can mean big savings. If you’d like help, I’ll review your medications, doctors, and benefits to make sure you’re in the right fit for January 1.

Other Developments

Some Medicare Advantage supplemental benefits (i.e. nutrition support, OTC medicine) may be reduced in favor of core services.
In six states, prior authorizations for certain Original Medicare services will be tested.
Part B and Part D premiums and deductibles are both set to increase—Part B premium up ~11.6%, and Part D premium by about 6%.

Who Am I?

In addition to being the editor of this blog I have has been helping individuals and families navigate the health and Medicare insurance landscape since 1986. With nearly four decades of experience, he specializes in Medicare Supplement, Medicare Advantage, and Medicare Part D prescription drug plans.

As an independent broker, I am appointed with virtually every competitive, A-rated Medicare insurance company in Texas, Indiana, Ohio, and Michigan. This broad access allows him to recommend the plan that truly best fits each client’s needs.

Above all, I work for my clients—not the insurance companies. You will never pay more by enrolling through me than you would if you purchased an insurance product directly from the carrier. My mission is to provide clear guidance, personalized recommendations, and ongoing support to ensure my clients get the coverage and peace of mind they deserve.

If you have any questions about 2026 Medicare Part D prescription drug plans, Medicare Advantage, or Medicare Supplement (Medi-Gap) policies, please give me a call.

D. Kenton Henry

Office: 281-367-6565
Text my cell 24/7 @ 713-907-7984
Email: Allplanhealthinsurance.com@gmail.com

For all the latest news on health and Medicare related insurance, please follow me on my blog @ Https://HealthandMedicareInsurance.com

https://TheWoodlandsTXHealthInsurance.com

**********************************************************************************

FEATURE ARTICLE 1

By: Elizabeth Casolo Friday, September 26th, 2025

Average premiums, benefits and plan choices for Medicare Advantage and the Medicare Part D prescription drug program should remain relatively stable next year, CMS said in a Sept. 26 news release. But MA enrollment is projected to decrease 900,000 in 2026.

Despite a slight dip in available MA plans nationally, over 99% of Medicare beneficiaries will still be able to access an MA plan.

The agency estimates the premiums for MA plans to drop from $16.40 to $14.00. On average, the total premium for standalone Part D is estimated to fall $3.81.
CMS’ July forecast predicted elevated Medicare Part D base premium increases in the neighborhood of 6%.

NAVIGATING THE FRUSTRATIONS OF FINDING INDIVIDUAL AND FAMILY HEALTH INSURANCE

Posted on March 21, 2025 by thehealthinsuranceanswerman

By D. Kenton Henry
Editor, Agent, Broker

Finding Your Doctor and Understanding Subsidies in HMO Plans

Shopping for individual or family health insurance can feel like navigating a maze—with dead ends, confusing signs, and few clear answers. Two of the most common pain points for shoppers are (1) trying to keep your current doctor while limited to an HMO network and (2) figuring out whether you qualify for a subsidy, known as an advance premium tax credit (APTC). Both challenges can make the process frustrating and overwhelming, especially during open enrollment when time is limited.

The HMO Headache: “Will My Doctor Be Covered?”

One of the biggest shocks people face when shopping for health insurance is realizing that their trusted doctor or medical provider might not be covered under a new plan—especially if it’s an HMO (Health Maintenance Organization). Unlike PPOs (Preferred Provider Organizations), which offer broader provider access and out-of-network options, HMO plans restrict coverage to a specific network of doctors and hospitals. If your doctor isn’t in the network, you may have to pay the full cost of your visit out of pocket—or switch doctors entirely.

Unfortunately, trying to find this information is often easier said than done.

Outdated or Inaccurate Provider Directories: Online directories can be incomplete or outdated. It’s not uncommon for a provider to be listed as “in-network” only for you to find out later they’ve left the plan.
Hard-to-Navigate Insurance Websites: Many insurance carrier sites don’t make it easy to search by doctor name, location, or specialty. Even worse, each plan may have its own “network tier,” adding another layer of complexity.
No Universal Search: There’s no centralized tool that lets you enter your doctor’s name and see every marketplace plan that includes them. You have to check each insurance company or plan individually.

For people with ongoing care needs—like managing chronic conditions or continuing with a trusted pediatrician or specialist—the possibility of switching providers isn’t just inconvenient, it can feel risky.

The Subsidy Puzzle: “Do I Qualify for Help Paying My Premium?”

The Affordable Care Act (ACA) made health insurance more accessible by offering subsidies for people who meet certain income guidelines. These subsidies, officially called advance premium tax credits, lower your monthly premium based on your household size and income.

The good news is that many people qualify.

The bad news is that determining whether you qualify can feel like filling out a tax return just to get a quote.

Income Guesswork: Subsidy eligibility is based on your estimated household income for the upcoming year. That’s right—you must predict your future income, even if you’re self-employed or work variable hours.
Family Dynamics Matter: Your household size includes dependents—even if they don’t need insurance—and income from every working member. This means getting it right often requires gathering data from multiple people.
Mid-Year Changes Complicate Things: If your income or family size changes mid-year, you may need to report it or risk having to repay part of your subsidy at tax time.
The ACA “Cliff” and “Glide Path”: Previously, you could lose your subsidy entirely if your income was even $1 over the limit. Recent changes have smoothed this out, but they are still complicated and frequently misunderstood.

And while tools like Healthcare.gov’s calculator are helpful, they often rely on broad estimates. They can’t account for all variables, such as gig work, investment income, or multiple part-time jobs.

Why It Feels So Frustrating

When you shop for health insurance, you’re not just picking a product—you’re making decisions that affect your finances, your family’s well-being, and your access to care. The stakes are high, yet the process often feels opaque and unnecessarily complicated.

You’re expected to:

Compare dozens of plans with unfamiliar terms,
Check if your providers are covered (without reliable tools),
Predict your income a year in advance,
And hope you don’t make a mistake that costs you money or coverage.

Tips for a Smoother Experience

While the system isn’t perfect, there are ways to reduce frustration:

Use a Licensed Agent or Broker: Agents specializing in ACA plans can often help you find plans that include your provider and determine if you qualify for subsidies—all at no extra cost.
Call Your Doctor’s Office: Don’t rely solely on insurance directories. Call your provider’s office directly to confirm if they accept a specific plan.
Keep Documentation: If your income fluctuates, keep clear records. This will help you provide accurate estimates and support your case in the event of an audit or dispute.
Update Changes Promptly: If your income or household size changes mid-year, report it on your health insurance marketplace to avoid surprise bills or tax penalties.

In Summary

Shopping for individual or family health insurance can be a stressful process—especially when you’re trying to keep your doctor and figure out if you qualify for financial help. Between restrictive HMO networks and confusing subsidy rules, it’s easy to feel stuck. But with a little extra diligence, some expert help, and the right questions, you can find a plan that fits your needs without sacrificing peace of mind.

If the process still feels overwhelming, you’re not alone. Many Americans share the same frustrations—and continue to hope for a more user-friendly system in the future.

Below is a chart outlining estimated income thresholds for qualifying for an Advance Premium Tax Credit (APTC) in 2025. These thresholds are based on a percentage of the Federal Poverty Level (FPL), which is adjusted annually. For simplicity, the chart includes 2024 FPL figures (used for 2025 coverage) and the income ranges (100%–400%+ of FPL) where most people qualify for subsidies under the ACA.

📝 Note: Due to the American Rescue Plan and Inflation Reduction Act, subsidies may extend beyond 400% of the FPL, with a sliding scale that caps the percentage of income spent on premiums. These extended subsidies are currently in place through 2025.

2024 Federal Poverty Level (FPL) and APTC Income Guidelines for 2025 Coverage

Household Size100% / FPL400% / FPLTypical APTC Eligibility Range

1 (Individual) $14,580 / $58,320 / $14,580 – ~$58,000+

2 (Couple) $19,720 / $78,880 / $19,720 – ~$79,000+

3 $24,860 / $99,440 / $24,860 – ~$99,000+

4 (Family) $30,000 / $120,000 / $30,000 – ~$120,000+

5 $35,140 / $140,560 / $35,140 – ~$141,000+

6 $40,280 / $161,120 / $40,280 – ~$161,000+

Key Notes:

Minimum Income: You must earn at least 100% of the FPL to qualify for a subsidy in most states. In Medicaid expansion states, if you earn less than 138% FPL, you may qualify for Medicaid instead.
Upper Limit Removed: Thanks to temporary reforms, people earning above 400% FPL may still qualify for a subsidy if the cost of the benchmark plan exceeds ~8.5% of their income.
Household Size: Includes you, your spouse, and any dependents claimed on your tax return.

💡 What This Means for You

If your estimated annual income falls between the ranges shown above, you likely qualify for help paying your monthly health insurance premium.
Households earning more than 400% of the FPL may still qualify if their premiums exceed about 8.5% of income, thanks to current federal subsidy expansions.
Eligibility is based on your tax household — including you, your spouse, and dependents you claim on your tax return.
If your income is below 138% FPL, you may qualify for Medicaid (in most states).

DO NOT CALL AN 800 NUMBER and talk to some anonymous employee of an insurance company. Not only are they restricted to limiting you exclusively to their company’s options—but your personal information will be instantly sold and shared. Your phone is going to begin ringing off the hook!

I’ve been specializing in Medicare-related insurance for over thirty years, right here in The Woodlands, Texas, USA! I represent every Medicare-related product, including Supplement, Advantage, and Part D Drug plans, from virtually every “A” rated company doing Medicare-related business in Texas. And I CHARGE NO FEE for my services! Deal with a local agent/broker who values your business enough not to share it with anyone!

D. Kenton Henry
Editor, Agent, Broker
Office: 281.367.6565
Text my cell 24/7 @713.907.7984
Email: Allplanhealthinsurance.com@gmail.com

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CONGRATULATIONS! YOU’RE TURNING AGE 65 AND ELIGIBLE FOR MEDICARE! (WHAT’S NEXT?)

Posted on March 20, 2025 by thehealthinsuranceanswerman

Congratulations! You’ve worked hard, and now you’re turning age 65!
Navigating through the myriad of solicitations you are receiving and
the choices you have to cover the expenses not paid by Medicare can be overwhelming.

The first thing is what not to do!

D. Kenton Henry
Editor, Agent, Broker
Office: 281.367.6565
Text my cell 24/7 @713.907.7984
Email: Allplanhealthinsurance.com@gmail.com

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NOW IS THE TIME TO RE-SHOP YOUR MEDICARE SUPPLEMENT POLICY!

Posted on January 28, 2025 by thehealthinsuranceanswerman

By D. Kenton Henry
Editor, HealthandMedicareRelatedInsurance.com
Agent, Broker
28 January 2025

Hello again, and welcome to 2025! Early last October, just prior to the Medicare Annual Election Period (AE), I informed you of the many changes coming to Medicare Part D Prescription Drug Plans in the coming calendar year in which we now find ourselves. I explained the pros and cons that many of you are now experiencing in real time. On the positive side, I am certain many are celebrating that their annual drug costs (for Part D covered drugs) can never go beyond the new annual maximum out-of-pocket (OOP) of $2,000! And, hopefully, you are not experiencing the negatives—such as learning your Rx drug (which was previously covered) is no longer or its price has increased dramatically! Once again, we realize the government can giveth or taketh away.

But there is one thing in which you have a certain amount of control, and this is the ideal time of year to exercise that control. During the AEP, insurance companies, agents, and brokers work overtime seven days a week to see that their clients, and prospective clients, are guided to the Medicare Advantage and Part D Drug plans that best meet their needs. To do this correctly, an agent must understand the client’s needs and objectives and then do, what is often, extensive research to ensure a person’s drugs are covered and they have access to their preferred providers. In some cases, this can take minutes and, in others, hours over repeated phone calls. In most cases, you won’t get the latter from a company employee on the end of an 800 number, but you will get it from me.

Now that the AEP ended December 7th, agents have much more time to assist you in improving the cost of your Medicare Supplement coverage. As you may know, Medicare Supplement is not subject to annual enrollment periods in Texas or most states. What this means, is you can re-shop your Supplement coverage to find identical (or improved) coverage 365 days per year. The incentive for doing so is that you may save 30% or more in premiums. Because Medicare Supplement premiums go up each year as we age, it doesn’t take too many years before most of us begin to wonder if our premium is still reasonable or competitive. The reality is, if your policy is three years or older, you will indeed safe significantly by switching to a policy with the same letter designation, e.g., Plan G. I have many clients whose policy premiums had increased to well over $300 per month that I was able to lower (with new coverage) to less than $200 per month!

Additional reasons to re-shop now are that a few “A” rated companies are particularly interested in expanding their block of business. This does not imply a compromise in the quality of their customer service or rate stability. It simply means that through prudent management and staff expansion, they can be more competitive, significantly lowering your premium. Additionally, you may now have a spouse, or in some cases, simply another adult living with you—making your new policy available for a “Household Discount”. Typically, these discounts can lower your premium 7-12%, and—if the other person is covered by the same company—that discount will apply to their existing policy also!

So what is the catch? The catch is that now that you have been in Medicare Part B 6 months or more, you must go through underwriting and be approved for the new coverage based on your current health and relatively recent health history. The bottom line is, if your current conditions are well controlled with medication, you do not suffer from any chronic condition that poses a long-term liability to the insurance company, and you have no pending surgeries or hospitalizations—you are a good candidate for replacement coverage. The worst scenario is you are declined. In this case, all you are out of is the small amount of time you took to complete the application.

THE FOLLOWING IS A SYNOPSIS OF THE PROS AND CONS OF RE-SHOPPING YOUR COVERAGE:

Re-shopping a Medicare Supplement (Medigap) policy can provide several advantages for recipients, especially if their needs or circumstances have changed since they first enrolled. Here are the key benefits:

1. Cost Savings

Premium Reduction: Medigap premiums can vary significantly between providers for the same coverage. Shopping around may uncover lower premiums for the same plan (e.g., Plan G or Plan N).
Health Status Discounts: If your health has improved since your initial enrollment, you might qualify for a lower premium rate with another insurer.
Household Discounts: Some insurers offer discounts if multiple members of the household enroll in their Medigap plans.

2. Better Coverage Options

Change in Needs: If your healthcare needs have increased or decreased, you might find a plan that better aligns with your current situation, such as switching from a high-deductible plan to one with lower out-of-pocket costs.
Additional Benefits: New Medigap plans might include perks like fitness programs, telehealth, or wellness benefits that weren’t available when you initially enrolled.

3. Access to New Insurers

Competitive Market: New insurers entering the market may offer attractive rates or better customer service than your current provider.
Provider Reputation: Switching to a more reputable insurer can improve your overall satisfaction and ensure reliable claims processing.

4. Avoiding Rate Increases

Age-Based Increases: Some policies increase rates as you age. Shopping around may allow you to switch to a community-rated policy where premiums are based on a group average rather than individual age.
Annual Adjustments: If your current insurer has raised premiums significantly, exploring alternatives can help you lock in a more stable rate.

5. Improved Customer Service

If your current insurer has poor customer service or limited support, switching to a provider with higher satisfaction ratings can enhance your overall experience.

6. Medicare Advantage Comparison

While re-shopping Medigap policies, some recipients may realize that a Medicare Advantage (Part C) plan is more cost-effective or suitable for their needs. These plans often include additional benefits like dental, vision, and hearing coverage.

7. Regulatory Benefits

Guaranteed Issue Rights: In some situations (e.g., losing coverage or moving), recipients have guaranteed issue rights, allowing them to switch Medigap plans without medical underwriting.
Trial Rights: If you tried a Medicare Advantage plan for less than 12 months and decide to switch back to Original Medicare, you may have a guaranteed right to re-enroll in a Medigap plan.

8. Customizing for Future Needs

Planning ahead for potential healthcare changes can ensure that you are prepared for costs that might arise later, such as skilled nursing care or extensive outpatient services.

Considerations When Re-Shopping

Medical Underwriting: Outside of guaranteed issue periods, you may need to answer health questions, which could affect your eligibility or rates.
Plan Standardization: All Medigap plans with the same letter (e.g., Plan G) offer identical core benefits, regardless of the insurer, making it easier to compare prices.
Timing: The best time to switch is typically during your open enrollment period or when you have guaranteed issue rights.

By re-shopping their Medigap policy, Medicare recipients can ensure they are getting the best value and coverage for their evolving needs.

I am an independent agent with more than three decades in the medical insurance industry. As I have aged, so have my clients, and Medicare-related insurance (Supplement, Advantage, Part D) has become my specialty. I represent virtually every “A” rated insurance company in Texas as well as three others. I provide objective advice based on empirical numbers inclusive of costs and satisfaction surveys.

Significantly, I do not charge a fee for my service. You are charged no more for acquiring a product through me than if you went in the front door of the insurance company whose product you elected and acquired it directly from them!

Please allow me to assist you in lowering the cost of your Medicare-related insurance. I look forward to working with you!

D. Kenton Henry

Office: 281-367-6565
Text my cell 24/7 @713-907-7984
Email: Allplanhealthinsurance.com@gmail.com

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CHANCES ARE YOUR MEDICARE ADVANTAGE AND DRUG PLAN PREMIUMS, COVERED DRUGS, OR GYM MEMBERSHIP WILL CHANGE

Posted on September 11, 2024 by thehealthinsuranceanswerman

By D. Kenton Henry
Editor, Agent, Broker
HealthandMedicareInsurance.com
11 September 2024

Welcome, fellow boomers and others blessed to have lived long enough to find yourself here. I believe you recognize that the information in my blog posts can contribute to this leg of our journey being the longest and most rewarding. I’m right here with you and doing my best to make it so for all of us. Coming changes in 2025 Medicare plans are significant, so please read this and feel free to take notes. They could impact you and probably will.

We will begin with what your Medicare Part B premium to Medicare for Out-Patient Care will go to:
For those earning less than $105,000 your premium will go to $185.00 (up from $174.70)
For those in the highest income bracket, earning greater than $500,000 your premium will go to $628.90 (from $594.00)
For every income block in between, couples filing jointly, and what Part D premiums to Medicare will go to, please click on this link and scroll down: https://www.irmaacertifiedplanner.com/2025-irmaa-brackets/

An Annual Notice of Change (AOC) from your Medicare Part D prescription drug plan or a private insurer’s Medicare Advantage plan is due you. It will arrive in the United States mail and, per Medicare rules, by September 30th. So, like the pretty woman in the image above, open it and read it. It outlines how much your premiums, deductibles, and co-pays will differ in the coming year. Will your drugs be covered, and will your current drug plan even be available? We don’t yet know. Mutual of Omaha notified agents and brokers that it is withdrawing altogether from the Part Drug plan market beginning January 1. If you are currently with them or have any other plan that is exiting the marketplace, follow the instructions in the next paragraph.

According to eHealth, a mere 36% of those surveyed claim the AOC to be “readily understandable.” The author of the attached article recommends you spend at least 30 minutes reviewing it. However, if you finish this article, you can cut that time considerably. If you have finished all and still feel you are among the remaining (up to) 64%—please call me @ 281-367-6565.

This article is a follow-up to my last blog post on September 3rd. “MAJOR CHANGES IN MEDICARE PART D DRUG PLANS ARE COMING OUR WAY (what we know. and one thing we don’t know).” To read it, please click on this link. (if necessary, copy and paste it in your browser’s URL box and hit enter):

https://healthandmedicareinsurance.com/2024/09/03/

Well, now we know more of the potential compromises mentioned or alluded to in that article. All of these are covered in detail in Feature Article 1 below.

The changes addressed here are largely because of the new $2,000 per year limit on Medicare Part D drug costs in 2025 (versus $8,000, plus 5% thereafter, in 2024). That leaves Medicare Part D insurance companies looking for ways to compensate for the additional costs shifting from you to them. Come January, you will meet a new deductible of up to $590 (from $545) for applicable drugs. Typically, your plan will apply this to brand-name drugs and not Tier 1 or Tier 2 generics.

Beyond that, the Gap, commonly referred to as the “donut hole” (in which you were previously responsible for 25% of your drug costs), has been eliminated entirely. You will have entered the “Initial Coverage” phase in which your elected drug plan will pay 65% of your applicable drug costs, and you will pay 25%. The Manufacturer (pharmaceutical company) will discount the remaining 10%. When you hit your maximum Out-of-Pocket (OOP) threshold of $2,000, you enter “Catastrophic Coverage”. At that point, your plan will pay 60%. Reinsurance (CMS, the Center for Medicare Services, i.e., the government) will pay 20%, and the Manufacturer will pay the remaining 20%. You will pay $0.

This, of course, sounds very well and good! And for those utilizing large quantities of drugs, or expensive drugs, this will indeed be of great benefit. But in what ways may the drug plans “compensate” for the additional costs they will bear? Much of such was referenced or alluded to above. However, please permit me to drill down on potential measures drug plans may take to offset their increased share of your drug cost. *(I am a Medicare Insurance product broker and not a C.P.A. As such, I will not address the impact on the taxpayer of their increased share of Medicare drug costs in this forum. wink. wink 😉

The drill down:

In addition to the higher deductible, higher premiums may be in store. But it could have been a lot worse. CMS did health insurance companies a favor with a “premium-stabilization” plan. In 2025, they will give them a subsidy in exchange for not “slapping members with exorbitant premium hikes. So, “what might have been a 40%, 50%, or higher premium increase may only be as high as 25%. Either way, it will be a sticker shock when some see how their premiums changed.” *(a paraphrase a quote in Feature Article 1)

The Kaiser Family Foundation says the average cost of a stand-alone Part D drug plan is $43. I have seen previews of premiums which will be $0, but others, have risen. In addition to your premium, co-pays for your drugs could go substantially higher. If your drug plan is obligated to charge you less for (or cover more of) a particular drug, are they simply going to charge you more for others?

And what about “Value Added Benefits” (VAB) available in some Medicare Advantage Plans? These include vision, hearing, and dental services. Other examples include acupuncture, bathroom safety devices, and wigs for hair loss. And what about your gym membership? Embedded dental insurance has been dramatically cut back or removed completely.

VAB are not covered by Original Medicare. Medicare Advantage has been able (often along with a $0 premium) to offer these things as an additional incentive to encourage enrollment in their plans. However, because you left Original Medicare and “assigned” the administration of your benefits and claims to the Advantage company when you enrolled, your plan can choose to provide these ancillary benefits that Original Medicare does not. Or they can choose to cover them no longer. This discretion is on their part because the provision of VAB benefits is not codified in law or per CMS regulation. Resultingly, they are not guaranteed. They are optional benefits that the plans have the right to withdraw at any time. I hope you can continue to “workout” at the gym, at your plan’s expense, in 2025 and beyond. But be prepared to purchase a home gym kit if you learn your membership is downgraded or your Advantage plan disappears entirely.

With no obligation, please feel free to contact me for clarification of these relevant issues and additional guidance in navigating the Medicare system and the changes referred to here. I’m in Medicare with you. I am a “Boomer” who has spent the better part of his life in the medical insurance market. For years, I have assisted individuals, families, and businesses in identifying and enrolling in health insurance plans that came as close as I could get them to fully meeting their medical insurance wants and needs.

To sum things up, I work for my clients. I work for you. Not the insurance company. I study, take their tests, and “certify” to represent their products each calendar year. I just completed certifying with approximately 14 companies in preparation for marketing their products in 2025. They do not pay to renew my licenses or my Errors and Omissions insurance, nor do they cover my office insurance and expenses. Neither they, nor anyone else, pay me wages or a salary. And that is great! I knew and understood those terms when I went out on my own. And that is precisely why I did it. I did not want to be beholden to the insurance company.

After becoming independent, the list of companies I was contracted with grew to over 40 during the 1990s. That number has changed as many of those companies went the way of the steam engine with “Obamacare” and all the red tape and regulations that come with it and remaining in the industry. But I persist. I remain positioned to provide you with virtually every available Medicare and health insurance product in your region.

In conclusion:

If you’re reading this, chances are you remember Jim Rockford (a private detective, portrayed by the actor the late James Garner) in his TV show, The Rockford Files (you can hear the opening music now, can’t you?). In the prelude to each episode, you see his cassette recording answering machine and hear the message, “This is Jim Rockford. At the tone, leave a message …”.

Should you get mine, please do the same. Or you may simply text me.

Donald Kenton Henry

Office: 281-367-6565
Text my cell 24/7 @ 713-907-7984
Email: Allplanhealthinsurance.com@gmail.com
Https://TheWoodlandsTXHealthInsurance.com
Https://Allplanhealthinsurance.com
Please follow me @ Https://HealthandMedicareInsurance.com

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FEATURE ARTICLE 1

FORTUNE
Richard Eisenberg
Updated Mon, Aug 26, 2024

Why this year’s Medicare Annual Notice of Change will be vital reading for beneficiaries

In this article:

If you’re on Medicare, you’ll be getting one or two Annual Notice of Change letters in your mail or email this September about your 2025 coverage and costs. You may be tempted to ignore what looks like junk, as nearly a third of recipients do, according to an eHealth survey.

Don’t.

“So often, a person who is quite happy with their plan and doesn’t bother to look at their Annual Notice of Change then gets a nasty surprise in January” when the plan’s new costs and coverage kick in, says Danielle Roberts, author of 10 Costly Medicare Mistakes You Can’t Afford to Make and founding partner of Boomer Benefits, which sells Medicare policies.

What is an Annual Notice of Change?

An Annual Notice of Change from your Medicare Part D prescription drug plan or a private insurer’s Medicare Advantage plan lays out how much your premiums, deductibles, and co-pays will differ in the year ahead and whether the plan will even be offered. (Medigap plans don’t send these notices because they don’t change much year to year.)

An Annual Notice of Change from your Part D plan also says whether your prescriptions will be covered and, if so, how much you’ll pay. A Medicare Advantage Notice of Change will tell you if your doctors and hospitals will remain in the plan’s network.

While this information is always essential to make smart choices during Medicare’s eight-week open enrollment period (Oct. 15 – Dec. 7), experts say reading your Annual Notice of Change is especially important in 2024.

“There is an excellent chance that something is changing on your plan,” says Roberts. “This year, more than ever, we can expect big changes in the plans.”

Surprising effect of the $2,000 prescription drug cap

That’s largely due to a major Medicare change coming in 2025: the new $2,000 cap on out-of-pocket costs for prescriptions covered by a Part D plan.

Since Part D health insurers will be on the hook for more prescription costs due to the cap, they’ll be looking for ways to compensate.

That could mean higher premiums (currently $43 a month for stand-alone plans, on average, according to KFF), deductibles, and co-pays—possibly substantially higher than in 2024.

“I have been very, very concerned about what the $2,000 cap was going to do to Part D premiums,” says Roberts.

The prescription drug change in 2025 could also lead to your Part D plan no longer covering certain medications you take or raising prices of ones it will.

Medicare Advantage plans—some facing profit squeezes currently—often include Part D coverage, so they may respond to the $2,000 cap by trimming or eliminating benefits to keep their popular $0 premiums intact, experts expect.

As a result, your Medicare Advantage benefits that original Medicare can’t offer—such as dental, vision, hearing, and gym memberships—could be less attractive than in 2024, or possibly gone entirely.

“It really will be important to understand what’s changing in the coming year in my current plan and does the plan still fit?” says eHealth CEO Fran Soistman. “Does it still provide the value that it did when I elected to go in it in the first place?”

Reading and understanding the Notice of Change

Your Annual Notice of Change will tell you—if you can understand it.

Only 36% of Medicare beneficiaries surveyed by eHealth said their Annual Notice of Change letter is “readily understandable.”

Figure on spending about 30 minutes closely reading your Annual Notice of Change to see exactly what will be different in 2025 and whether you’ll want to switch plans or coverage next year as a result.

During open enrollment, you can switch from your current Part D plan to another, from your Medicare Advantage plan to another, from Medicare Advantage to original Medicare as well as from original Medicare to a Medicare Advantage plan.

But don’t feel compelled to switch plans just because your Annual Notice of Change says your premium will go up a little or a benefit will be trimmed slightly.

“If there’s a modest benefit decrease or premium increase, but they’re satisfied with what the carrier is providing, people shouldn’t make a change,” Soistman says.

However, he added, if a medication you take will no longer be covered or your physician or hospital won’t be in network, that’s an important change that may persuade you to switch coverage.

The Medicare Plan Finder on Medicare’s site will let you compare Part D and Medicare Advantage plans for 2025.

And, as Philip Moeller writes in the forthcoming revised edition of his book, Get What’s Yours for Medicare, if your Medicare Advantage plan won’t include your favorite doctor or hospital in its network in the year ahead, it’s legally obligated to work with you to identify other physicians or hospitals in its network that you’d like.

A new program to help avoid big premium hikes

To help prevent drastic Part D premium increases, the government’s Centers for Medicare and Medicaid Services recently threw a bone to health insurers with a premium-stabilization plan.

Medicare will provide a special subsidy to those insurers for 2025 in exchange for avoiding slapping members with exorbitant premium hikes.

“It should take what might have been a 40%, 50%, or higher premium increase down to probably 25%,” says Soistman. “It’s still going to be a bit of sticker shock when some people see how their premiums changed.”

Roberts says, “I’m still somewhat concerned about premiums, but I feel a little better after the stabilization program announcement.”

Getting help if your Medicare plan will change

After reading your Annual Notice of Change, you may want to get help deciding on the right Medicare plans for 2025 and to understand the implications of coming changes to your plans.

You can ask a Medicare broker or agent for assistance; there’s a directory at the National Association of Benefits and Insurance Professionals site. The sooner you do, the better, since agents and brokers will be swamped near the end of open enrollment.

“At Boomer Benefits, we have to stop taking new requests after Thanksgiving,” says Roberts.

If one of your prescriptions won’t be covered by your Part D plan in 2025, call your doctor to see if another covered medication would be okay or if you should find a new plan that includes it, Roberts advises.

For information about Part D and Medicare Advantage plans without purchase recommendations, try your State Health Insurance Assistance Program or visit Medicare’s site or call Medicare’s toll-free number.

More time for open enrollment?

Soistman believes all the changes coming to Part D and Medicare Advantage plans for 2025 will push back the arrival of the Annual Notice of Change documents to the last two weeks of September.

If so, this will give people with the plans less time than normal to read the notices before open enrollment.

The eHealth agency has asked the Centers for Medicare and Medicaid Services to extend open enrollment by about five days to give beneficiaries, insurers, and Medicare brokers more time. Boomer Benefits favors the extension, too.

So far, the government hasn’t responded to eHealth’s proposal.

Could the 2025 open enrollment become Medicare’s equivalent of the Department of Education’s FAFSA financial-aid form fiasco of chaos and confusion?

“I don’t think it will be quite as drastic. I think it is going to be a year of change, though,” says Soistman. “And change is hard for people.”
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Please follow me follow D. Kenton Henry @ Https://HealthandMedicareInsurance.com

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Monthly Medicare Part B premiums will fall to $164.90 in 2023, marking a $5.20 decrease from this year, while Part A premiums are set to increase by $4 to $7.

Dig Deeper

As prescription drug spending climbs, ACHP is calling on policymakers to reduce high prescription drug prices and enhance market competition.

Dig Deeper

Employer vs. Individual Coverage

The Reality of Dental Costs

1. “Reasonable and Customary” Limits

2. Network vs. Non-Network Plans

Network Plans (Recommended)

Non-Network Plans

3. The Most Important Rule: Avoid Excess Charges

Finding the Right Dentist (and Plan)

Understanding Benefit Limits

A Real-World Strategy (From Experience)

Bottom Line: How to Make Dental Insurance Work

✔ Choose a network plan

✔ Match benefits to your expected needs

✔ Select a skilled, in-network dentist

✔ Work with a knowledgeable advisor

How I Can Help

Let’s Talk

Final Thought

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HOT OFF THE PRESSWhat Changed?

What This Means

Example

Important Requirements

Why This Matters

Need Help Reviewing Your Options?

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a New Opportunity to Change Your Medicare Supplement Plan Without Health Questions

What the Indiana Birthday Rule Allows

Key Requirements to Qualify

1. You Must Currently Have a Medicare Supplement Policy

2. You Must Be Replacing Your Plan With the Same or Lower Benefits

3. You Must Apply at Least 60 Days Before Your Birthday

Medical Underwriting Is Waived

Why This Rule Matters

Should You Review Your Plan?

I Am Here to Help

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The HMO Headache: “Will My Doctor Be Covered?”

The Subsidy Puzzle: “Do I Qualify for Help Paying My Premium?”

Why It Feels So Frustrating

Tips for a Smoother Experience

In Summary

2024 Federal Poverty Level (FPL) and APTC Income Guidelines for 2025 Coverage

Key Notes:

💡 What This Means for You

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HOT OFF THE PRESS

What Changed?