By Tim Wholf

Medicare participants will see a number of changes in the program in 2025. With Open Enrollment now underway until Dec. 7, it’s a good time to summarize what will soon take effect.

1. $2,000 out-of-pocket spending cap for prescriptions

One of the biggest changes taking effect in 2025 is Part D plans must cap out-of-pocket spending on covered drugs at $2,000 a year. The $2,000-a-year out-of-pocket limit for prescription medications applies to stand-alone Medicare Part D policies and drug coverage in Medicare Advantage plans.

The cap includes deductibles, copayments and coinsurance for covered drugs. It doesn’t apply to premiums or non-covered drugs. Such a significant change means that during Open Enrollment it is important to shop as there could be a plan that better suits one’s health and financial needs.

2. No more Part D coverage gap

This change simplifies the way Part D works. In 2025, Part D plans can have a deductible up to $590. Individuals pay copayments for medications until their total out-of-pocket costs reach $2,000. Some have expressed concern that the $2,000 cap would lead to higher premiums. The cap doesn’t include premiums.

The 2025 Part D base premium is $36.78, but actual premiums vary depending on location and plan. Individuals may see a big variation in premiums, copayments and covered drugs during open enrollment this year. It is important individuals take time to compare coverage plans during open enrollment.

3. More ways to get weight loss drugs

Medicare is prohibited from covering drugs prescribed specifically for weight loss. However, Part D plans can cover popular weight loss drugs when they’re ordered for other purposes, such as type 2 diabetes or cardiovascular disease. Some weight loss drugs may be subject to relatively high cost-sharing because of their high price, but Part D enrollees who take these drugs will benefit from having the new $2,000 cap on their drug expenses.

4. Subtle changes to Medicare Advantage coverage

The $2,000 out-of-pocket spending cap applies to deductibles, copayments and coinsurance in the prescription drug portion of Medicare Advantage plans. Medicare Advantage plans may make changes in 2025 to help cover their additional expenses.

A plan may change its list of covered drugs; reduce its out-of-pocket maximum spending limit; increase the percentage one pays for coinsurance; or reduce some of their extra benefits. Review the details in the Explanation of Benefits on the plan’s website before making a final decision and reconfirm providers are still in the plan’s network.

5. Midyear statement from your Medicare Advantage plan

For beneficiaries who have chosen Advantage plans instead of original Medicare, this will matter. The midyear statement will show available benefits that individuals haven’t used. If an individual hasn’t used any of their dental, vision, hearing or fitness benefits, plans are required to notify them if they have any benefits left.

6. More mental health providers to Medicare

Before this year, licensed marriage and family therapists, mental health counselors and addiction counselors couldn’t bill Medicare because they weren’t allowed to enroll as Medicare providers. Now they can, and some have. Medicare Advantage plans must meet stricter standards to improve access to behavioral health specialists.

During Open Enrollment, it is extremely important to compare coverage options and change plans if necessary. A recent article by KFF.org indicated 69% of Medicare beneficiaries did not compare their source of Medicare coverage with other Medicare options offered in their area.

If individuals need assistance in comparing plans, they can reach out to the Senior Health Insurance Counseling for Kansas (SHICK) in Johnson County at 913-715-8856.

Tim Wholf is director of the Johnson County Department of Aging and Human Services.