The Biggest Changes Coming to Medicare in 2023

Starting July 1, Medicare members who take their insulin through a pump as part of the Part B durable medical equipment benefit will waive a deductible and will also benefit from a $35 copay limit.

Another provision of the new law requires that some high-priced drugs be subject to price negotiation with drug manufacturers. So, although the maximum monthly copay for Medicare-covered insulins will be $35 in 2023, 2024, and 2025, beginning in 2026 (first year negotiated pricing will take effect) covered insulin copays for any drugs that have been part of new negotiations will be $35 or 25 percent of the negotiated price, whichever is less.

free vaccines

Also under the new law, vaccines recommended for adults by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) will be available to Medicare beneficiaries free of charge.

Some vaccines are covered under Part B and are already free for Medicare members. Others are covered by Part D prescription drug plans and require beneficiaries to pay part of the cost.

For example, flu, pneumonia, COVID-19 (initial and booster shots), and hepatitis B vaccines for some members are free under Part B and that coverage will continue in 2023. Part B also covers vaccines needed to treat certain injuries or if you have direct exposure to disease. These include hepatitis A, rabies, and tetanus.

Other vaccines, particularly the two-dose Shingrix, which protects against shingles, are covered by Part D prescription drug plans and may require cost sharing depending on the plan. Shingrix, for example, can cost up to $200 per dose. Starting in 2023, even if a beneficiary hasn’t met their Part D deductible, that vaccine and others recommended by ACIP will be free to beneficiaries.

Pharmacists face fines for price gouging

Another provision of the new law that will go into full effect in 2023 requires pharmaceutical manufacturers to pay a reimbursement to Medicare if they raise their drug prices above the general rate of inflation.

Starting in 2023, companies that sell both Part D prescription drugs, which are bought at pharmacies, and Part B drugs, which are usually administered in doctors’ offices, will face penalties if they raise prices higher. than the inflation rate. Rebates due from companies will be the amount they raised the price of a drug above an increase to match inflation, multiplied by what Medicare paid for all sales of that drug.

This new requirement is intended to discourage pharmaceutical companies from raising their prices above inflation. According to research by the nonpartisan Kaiser Family Foundation, from 2019 to 2020 the prices of half of all drugs covered by Medicare increased more than the rate of inflation.

Beginning of price negotiations

By September 1, Medicare will announce the first 10 Part D drugs that, under the new law, will begin a first process in which Medicare will negotiate prices with drugmakers, Seshamani said, and that “will have a big impact.” to provide more affordability.” for drugs for people with Medicare.”

Negotiated prices for that first group of drugs, which will be selected from the 50 drugs that Medicare prescription drug plans spend the most on, will take effect in 2026.

Some telehealth rules will change

During the pandemic, Medicare expanded the availability of telehealth. This included allowing patients to speak with providers over the phone, not just face-to-face video calls, which is what Medicare rules required. The government also expanded the types of providers that would be available for telehealth visits, including physical, occupational, and speech therapists.

The expansion of these additional services and the way telehealth visits can be delivered was possible because Medicare officials were able to temporarily waive existing rules due to the coronavirus public health emergency. But once the emergency declaration is lifted, many of those additional services will only be available for another 151 days, Seshamani says. Congress would have to act to extend these pandemic expansions or make them permanent.

One area where the new flexibilities of telehealth have become permanent is behavioral health. Beneficiaries will continue to be able to access these visits only by phone, in addition to video.

Increased emphasis on behavioral health

“There is a lot to come in terms of mobilizing the behavioral health workforce,” says Seshamani.

Medicare will pay for licensed clinical social workers, psychologists, and other behavioral health specialists to be part of a beneficiary’s primary care office visit “so they can get their behavioral health services right there, to get care to the whole person.” Seshamani says. The program will also improve access to licensed marriage and family therapists.

In addition, Medicare will expand its substance abuse services. “We are going to pay for mobile vans, for example, for opioid treatment to bring care to where the people are,” says Seshamani.

Some access to dental care

Medicare does not cover routine dental care. It does pay for some dental work that is needed in conjunction with another medical procedure, such as the extraction of a tooth during jaw surgery. Beginning in 2023, the program will expand the type of “medically necessary” dental services it will cover when needed with other procedures, such as a cleaning or other dental work that will improve the outcome of an organ transplant or cancer treatment.

Enrollment access improved

Starting in January, as long as people eligible for Medicare enroll during the official enrollment periods, they won’t have to wait for their coverage to take effect. Also under a new federal regulation, more special enrollment windows have been established, including for people who, through no fault of their own, did not enroll when they were first eligible.

Before this new rule, people who signed up for Medicare late, usually within three months of turning 65, sometimes had to wait two or three months for coverage to take effect. For example, enrolling during the general enrollment period (January 1 to March 31) meant waiting for coverage to begin in July.

Starting in 2023, whenever you apply for Medicare during the General Enrollment Period or during a Special Enrollment Period, your coverage will be effective at the beginning of the following month.

People eligible for some of the new special enrollment periods include: people who missed their initial enrollment period because they were affected by a natural disaster; and individuals who were given misinformation by an employer that led them to not enroll when they were supposed to. In addition, people who no longer qualify for Medicaid, the federal-state health insurance program for low-income people, will be able to apply for Medicare during a special enrollment period if they lose their Medicaid coverage. Seshamani said this will be especially important as the COVID-19 public health emergency lifts.

Dena Bunis covers Medicare, health care, health policy and Congress. She also writes the Medicare Made Easy column for the AARP Newsletter. Bunis, an award-winning journalist, spent decades working for metropolitan dailies, including as Washington bureau chief for The Orange County Registry and as a health and workplace policy writer for news.

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