Webinar Replay

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Overview

The webinar provided an in-depth update on Medicare Open Enrollment for 2026, including new cost thresholds, Part D drug plan changes under the Inflation Reduction Act, and state-specific rules for Medigap policies. It also introduced tools like Hey Moe and i65, which help advisors and clients navigate Medicare plan comparisons.

2026 Medicare Open Enrollment Overview

Enrollment Period:
October 15 – December 7, 2025 (effective January 1, 2026).

Key 2026 Cost Changes:

• Part B Premium: Projected $206 per month (official figures to be confirmed by CMS in late November 2025).
• Part D Deductible: Increasing from $590 to $615.
• Out-of-Pocket Cap (Part D): Increasing from $2,000 to $2,100.

Melinda noted that fewer than 30% of Medicare beneficiaries review or change their plans annually — a missed opportunity, since plan changes can lead to major savings. She cited real-life examples of clients saving $235,000 and $149,000 simply by switching plans.

Impact of the Inflation Reduction Act (IRA)

Key Structural Changes

• Two Payment Phases (Starting 2025): The traditional four phases (deductible, initial, coverage gap, catastrophic) are being reduced to:
  1. Deductible phase
  2. Initial coverage phase, with a hard $2,000 out-of-pocket limit.
• After reaching the $2,000 threshold, drug manufacturers must cover 20% of remaining costs — a provision designed to keep medications affordable.

Cost Implications

• Beneficiaries will see no out-of-pocket costs beyond the $2,100 cap in 2026.
• Part D plans and drug manufacturers are adjusting to new cost-sharing rules, which may lead to premium increases and reduced plan availability.
• Part D Plan Participation: The number of participating carriers is shrinking, with fewer choices projected for 2026.
• Higher utilization management (step therapy, prior authorizations) is becoming more common.

Drug Coverage and Biosimilars

• Melinda emphasized checking formulary coverage, since some high-cost drugs — including Humira — will not be covered by any 2026 Part D plan.
• She urged beneficiaries to talk to doctors about switching to biosimilar versions (such as Amjevita and Hadlima).
• The new cost structure favors lower-priced biosimilars under the Medicare Prescription Payment Plan, offering beneficiaries monthly capped payments beginning in 2025.

Medicare Advantage and Original Medicare Updates

Key Differences and 2026 Changes

Melinda warned that extra perks like gym memberships, dental benefits, and meal delivery are being scaled back in 2026. She also highlighted the increasing complexity of Advantage plan networks and agent incentives that may not align with client interests — since commissions are higher for Medicare Advantage than Medigap policies.

Medigap Plans and the Birthday Rule

Understanding the Birthday Rule

• The Birthday Rule allows Medigap policyholders to switch carriers without medical underwriting during their birthday month and the following 60 days.
• Not available in all states.
  • Applies: California, Oregon, Idaho, Illinois, Nevada, Maryland, and Missouri (some with variations).
  • Does NOT apply: Pennsylvania, Washington (unique restrictions).
• Tom Dickson clarified that the rule applies only to Medigap-to-Medigap changes, not for switching from a Medicare Advantage plan back to Original Medicare.

State Examples

• Washington State:
  • Medigap costs are among the highest in the nation due to carrier restrictions.
  • Plans must accept all applicants for Plan A and limited versions of Plans F and G, increasing insurer risk and driving up premiums.
  • Monthly costs range from $114 to $466, depending on age and plan.
  • Melinda recommended Plan N or High Deductible G as cost-effective alternatives.
• Pennsylvania:
  • No birthday rule; changing carriers requires medical underwriting.
  • Tom shared that his premiums remain low because he locked in a “plan-for-life” option early, avoiding annual increases.

Choosing Medigap Plans Wisely

Melinda advised evaluating:

• Enrollment size of the plan (smaller pools tend to face higher premium increases).
• Profitability trends, since highly profitable carriers tend to raise premiums more aggressively.
• Rate history, which can signal stability or volatility.
  She also noted that Plan G remains the most popular for comprehensive coverage, but Plan N often provides 90% of the same benefits at lower cost.

Open Enrollment Triage for Advisors and Clients

Melinda outlined a triage checklist for the Open Enrollment season:

1. Review coverage annually, especially if:
   • Health conditions or medications have changed.
   • The client takes brand-name drugs.
   • The client’s spouse is on the same plan.
2. Re-evaluate Medigap options if premiums have risen more than 10%.
3. Use digital tools like Hey Mo and i65 to streamline comparisons.
4. Consult Medicare.gov carefully, as data inaccuracies and “ghost plan” listings have been noted in recent years.

Tools for Medicare Planning

1. Hey Moe – https://www.heymoe.com

• Helps beneficiaries and advisors compare Part D drug plans, track coverage changes, and receive automated alerts when plan costs shift.
• Integrates user prescription lists and preferred pharmacies.
• Can send personalized reminders for Open Enrollment and plan renewals.

2. i65 – https://www.i65.com

• Designed for financial planners to guide clients turning 65.
• Uses algorithms and data from the Centers for Medicare & Medicaid Services (CMS).
• Produces customized reports to recommend timing, coverage type (Advantage vs. Original), and cost estimates.

Tom Dickson praised both platforms, noting they enhance advisor credibility and client retention by simplifying a complex topic.

Key Takeaways

• The Inflation Reduction Act continues to transform Medicare Part D, simplifying cost structures and reducing beneficiary exposure to high drug expenses.
• Plan reviews are critical — even small annual changes can yield thousands in savings.
• Medigap plan costs vary widely by state and depend heavily on state-level rules.
• Advisors should focus on:
  • Helping clients verify doctor and drug coverage.
  • Checking for biosimilar substitution opportunities.
  • Reviewing carrier profitability and rate history before switching Medigap providers.
• Digital tools like Hey Mo and i65 can streamline the annual review process and improve decision accuracy.

Action Items

• Compare current Medicare and drug plans before December 7, 2025.
• Discuss with healthcare providers about switching from Humira to biosimilars like Amjevita or Hadlima.
• Evaluate Plan N or High-Deductible Plan G for clients in Washington State.
• Use Hey Moe and i65 to analyze plan options.
• Stay informed about the final 2026 Medicare cost announcements via https://www.cms.gov.