Scott Burge Insurance

05/15/2026

Understanding the 2026 Medicare Part D Out-of-Pocket Cap: What It Means for You

Medicare beneficiaries facing high prescription drug costs received welcome relief in 2026 with a key change to Part D coverage. Starting this year, the annual out-of-pocket maximum for covered Part D drugs is capped at $2,100. Once you reach this limit, you pay nothing more for covered prescription medications for the rest of the calendar year—no copays or coinsurance.10

This cap represents a major step forward from the Inflation Reduction Act. In previous years, beneficiaries could face thousands of dollars in drug costs even after entering the catastrophic coverage phase. Now, the $2,100 threshold provides predictable protection, especially helpful for those managing chronic conditions like diabetes, heart disease, or arthritis that require ongoing medications.5

How the 2026 Part D benefit works

Deductible Phase: You pay the full cost of drugs until you meet your plan’s deductible (up to $615 maximum in 2026 for many plans).

Initial Coverage Phase: You typically pay 25% of drug costs while your plan covers the rest.

Catastrophic Phase: Once your total out-of-pocket spending hits $2,100, Medicare covers 100% of covered Part D drugs for the remainder of the year.9

Additional savings continue on insulin (capped at $35 per month’s supply for covered products) and certain vaccines. Medicare is also negotiating prices on more high-cost drugs, which should further lower costs for many popular medications in 2026 and beyond.14

What should you do now?
Review your Annual Notice of Change (ANOC) carefully. Compare your current Part D plan’s formulary, premiums, and network pharmacies during the Annual Enrollment Period (October 15–December 7). Tools like Medicare’s Plan Finder can help estimate your total costs based on the specific drugs you take.

If you have high drug expenses, a plan with a lower deductible or better coverage in the initial phase might save you money—even with the new cap. Don’t hesitate to reach out for personalized guidance to make sure your plan aligns with your health needs and budget this year.

This article is for educational purposes only. Medicare rules can be complex—consult a licensed agent or visit Medicare.gov for details specific to your situation.

The official U.S. government website for Medicare, a health insurance program for people age 65 or older and younger people with disabilities.

04/27/2026

Don’t hesitate to call me

10/01/2025

Come visit me every Wednesday through December 3rd at the United Healthcare kiosk at the Scappoose Fred Meyer from 9am to 1pm

05/05/2025

New for health insurance.

The proposed merger of Legacy Health and Oregon Health & Science University will not move forward.

04/07/2025

Medicare’s Extra Help program, officially known as the Low-Income Subsidy (LIS), is a federal program designed to assist eligible Medicare beneficiaries with limited income and resources in paying for prescription drug costs under Medicare Part D. Here’s a breakdown of what it entails, how it works, and who qualifies:
What It Covers
The Extra Help program helps cover:
• Premiums: Reduces or eliminates the monthly premium for a Medicare Part D prescription drug plan.
• Deductibles: Lowers or removes the annual deductible.
• Copayments/Coinsurance: Significantly reduces out-of-pocket costs for covered medications, often to a small fixed amount (e.g., a few dollars per prescription).
• Coverage Gap: Provides assistance even during the “donut hole” (a gap in Part D coverage where beneficiaries once paid full price), though recent legislative changes, like the Inflation Reduction Act of 2022, have begun phasing out this gap entirely by 2025.
In 2025, with the donut hole closed, Extra Help beneficiaries continue to benefit from low or no-cost prescriptions year-round, depending on their income level.
Eligibility
To qualify for Extra Help, individuals must:
• Be enrolled in Medicare (Part A or Part 😎.
• Have limited income and resources:
◦ Income: For 2025, the income limit is typically around 150% of the Federal Poverty Level (FPL). For example, in 2024, this was roughly $20,385 for an individual or $27,465 for a married couple (adjusted annually, so 2025 figures may be slightly higher).
◦ Resources: Assets like savings or investments must be below a certain threshold, e.g., $17,220 for an individual or $34,360 for a couple in 2024 (excluding your home, car, and personal belongings). These limits are also adjusted yearly.
• Live in one of the 50 states or Washington, D.C.
There are two levels of assistance:
• Full Subsidy: For those with the lowest incomes (e.g., below 135% FPL) and who qualify for Medicaid or certain Medicare Savings Programs.
• Partial Subsidy: For those with slightly higher incomes (up to 150% FPL), offering reduced but still significant help.
How to Apply
• Automatic Enrollment: Some people are automatically enrolled if they receive Medicaid, Supplemental Security Income (SSI), or a Medicare Savings Program.
• Manual Application: Others can apply through the Social Security Administration (SSA) online at ssa.gov, by phone (1-800-772-1213), or in person. The process is straightforward and doesn’t require extensive documentation—SSA verifies income and resources with the IRS.
Benefits in Practice
For someone with Extra Help, a prescription that might cost $50 out-of-pocket without assistance could drop to $4 or less for generics and $10 or less for brand-name drugs (2024 figures; 2025 copays may adjust slightly). This can be a lifeline for seniors or disabled individuals managing chronic conditions like diabetes or heart disease.
Recent Changes
The Inflation Reduction Act has enhanced Medicare Part D overall, capping out-of-pocket drug costs at $2,000 annually starting in 2025 for all beneficiaries. For Extra Help recipients, costs remain even lower, often near zero, making it one of the most generous drug assistance programs available.
Challenges
• Awareness: Many eligible people don’t know about it or assume they won’t qualify.
• Complexity: Navigating Medicare Part D plans to maximize Extra Help benefits can be tricky, as not all plans align perfectly with an individual’s medication needs.
• Annual Changes: Beneficiaries must sometimes switch plans yearly to keep costs low, as formularies and premiums shift.

Official website of the U.S. Social Security Administration.

03/31/2025

Medicare Supplement plans, also known as Medigap plans, are private insurance policies designed to help cover some of the out-of-pocket costs that Original Medicare (Parts A and D.) doesn’t pay for, such as copayments, coinsurance, and deductibles. These plans are offered by private insurance companies and work alongside Original Medicare to provide additional financial protection for beneficiaries. They’re particularly useful for people who want more predictable healthcare costs or who anticipate needing frequent medical services.

There are 10 standardized Medigap plans, labeled A, B, C, D, F, G, K, L, M, and N, each offering a different combination of benefits. The standardization means that, for example, a Plan G from one insurer covers the same things as a Plan G from another, though premiums can vary based on the company, location, and pricing method (e.g., age-based or community-rated). Here’s a quick rundown of what some of the most popular plans typically cover:

- **Plan A**: The most basic, covering essentials like Medicare Part A coinsurance and hospital costs (up to an additional 365 days after Medicare benefits are used up), Part B coinsurance or copayments, and the first three pints of blood.
- **Plan F**: The most comprehensive, covering all the gaps in Original Medicare, including Part A and B deductibles, excess charges, and foreign travel emergencies. (Note: Plan F is no longer available to new Medicare enrollees as of January 1, 2020, but those enrolled before then can keep it.)
- **Plan G**: Similar to Plan F but doesn’t cover the Part B deductible. It’s become a popular choice for new enrollees due to its broad coverage and slightly lower premiums compared to F.
- **Plan N**: Covers most gaps but requires copays for some doctor visits and emergency room trips, offering a balance between coverage and cost.

A few key points: You need to be enrolled in Original Medicare (Parts A and D.) to buy a Medigap plan—Medicare Advantage plans (Part C) are a separate path and don’t pair with Medigap. Also, these plans don’t cover prescription drugs; for that, you’d need a standalone Medicare Part D plan. Premiums vary widely depending on factors like your age, location, and the insurer, and they’re in addition to your Part B premium.

The best time to buy a Medigap plan is during your six-month open enrollment period, which starts the month you turn 65 and enroll in Part B. During this window, insurers can’t deny you coverage or charge more based on pre-existing conditions. Outside that period, you might face medical underwriting, which could lead to higher rates or denial unless you qualify for a special enrollment circumstance.

Each plan fits different needs—someone healthy might go for a cheaper option like Plan N, while someone with chronic conditions might prefer Plan G for its near-full coverage. It’s a trade-off between monthly premiums and how much you’re willing to pay out of pocket when care happens.

03/29/2025

What is Medicare Part D?

Medicare Part D is the federal prescription drug benefit for Medicare beneficiaries in the United States, launched in 2006 under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. It provides coverage for outpatient prescription drugs through private insurance plans approved by Medicare. Unlike Parts A and B, which are government-run, Part D operates via private insurers, offering beneficiaries a choice of plans with varying costs and drug formularies. It’s optional, but it’s a key component for managing medication costs.
Who Qualifies?
Anyone enrolled in Medicare Part A (hospital insurance) or Part B (medical insurance) can join a Part D plan. This includes people 65 or older, as well as those under 65 with qualifying disabilities or end-stage renal disease. Eligibility isn’t tied to income—just Medicare enrollment and U.S. residency. Low-income beneficiaries can qualify for the Extra Help program (Low-Income Subsidy), which drastically reduces premiums, deductibles, and copays.
How Does It Work in 2025?
Part D plans are structured around a simplified cost-sharing model in 2025, thanks to the Inflation Reduction Act of 2022. You choose a plan during your Initial Enrollment Period (around age 65) or the Annual Enrollment Period (October 15–December 7). Late enrollment without prior creditable coverage triggers a permanent penalty added to your premium. Here’s the 2025 framework:
1 Deductible: Plans can charge up to $590 annually, though some have $0 deductibles. You pay 100% of drug costs until this is met.
2 Initial Coverage: After the deductible, you pay copays or coinsurance (often 25% for generics or brands, though it varies by plan) for covered drugs. This continues until your total out-of-pocket costs—deductible plus copays/coinsurance—reach $2,000.
3 Out-of-Pocket Cap: Once your out-of-pocket spending hits $2,000, you enter catastrophic coverage, where you pay $0 for all covered Part D drugs for the rest of the year. This $2,000 cap, effective January 1, 2025, replaces the old “donut hole” and higher thresholds (e.g., $8,000 in 2024).
• Key Note: The $2,000 cap only includes what you pay (deductible, copays, coinsurance), not what the plan pays. Drug costs beyond this are fully covered by the plan and Medicare, with no additional cost to you.
What Does It Cover?
Part D covers outpatient prescription drugs you pick up at a pharmacy—think pills, inhalers, or self-administered injectables (e.g., insulin via pens). Each plan has a formulary (list of covered drugs), which must include at least two drugs per therapeutic category and nearly all drugs in six “protected classes” (e.g., anticonvulsants, antipsychotics, HIV meds). Covered vaccines like shingles or flu shots fall under Part D too, unless administered in a doctor’s office (then it’s Part 😎. Exclusions typically include over-the-counter drugs, weight-loss meds, fertility drugs, and cosmetic treatments (e.g., hair growth).
Costs in 2025
• Premiums: Vary by plan, averaging $40–$60/month nationally, though some are as low as $0 and others exceed $100. Premiums depend on your region and plan generosity.
• Out-of-Pocket: Deductible (max $590), plus copays/coinsurance until you hit $2,000 total. After that, $0.
• Extra Help: For low-income enrollees, premiums can drop to $0, generics cost ~$4, and brands ~$10, with no deductible in many cases.
• Total Program: Covers ~50 million people, costing Medicare roughly $130 billion annually, though the cap may shift spending dynamics.
Enrollment and Penalties
You join via a standalone Part D plan (PDP) if you’re on Original Medicare, or through a Medicare Advantage plan with drug coverage (MA-PD). Missing enrollment without other creditable drug coverage (e.g., employer plans) incurs a penalty: 1% of the national base premium (~$34.70 in 2025) per month delayed, added permanently to your premium.
Why It’s Significant
Part D fills a gap left by Original Medicare, which doesn’t cover outpatient drugs. The 2025 $2,000 cap—down from complex prior phases—makes costs predictable, a win for seniors on fixed incomes. Critics still point to private insurer profits and limited drug price negotiation (though the IRA began addressing this with select drugs), but it’s undeniably reduced uninsured drug costs since 2006.

That’s Medicare Part D in 2025, accurate and streamlined. If you want more on premiums, formularies, or anything else, just say the word!

03/26/2025

Latest on UHC and OHSU negotiations:

Starting April 1, 2025, OHSU, Adventist Health Portland and Hillsboro Medical Center may no longer be in-network with UnitedHealthcare (United Healthcare, UHC).

03/04/2025

Medicare Part C, also known as Medicare Advantage, is an alternative to Original Medicare (Parts A and B.) offered by private insurance companies approved by Medicare. It bundles coverage for hospital care (Part A), medical services (Part B.), and often prescription drugs (Part D) into a single plan, sometimes with additional benefits not available under Original Medicare. Introduced in 1997 as “Medicare+Choice” and renamed “Medicare Advantage” in 2003, it’s designed to provide flexibility and choice for beneficiaries.
What Does Medicare Part C Cover?
Medicare Part C plans must cover everything that Original Medicare (Parts A and B.) does, including:
• Hospital stays, skilled nursing, and hospice care (Part A).
• Doctor visits, outpatient care, preventive services, and durable medical equipment (Part B.).
However, many Part C plans go beyond this, offering:
• Prescription drug coverage (similar to Part D, though not all plans include it).
• Extra benefits like dental, vision, hearing, wellness programs, or gym memberships, which Original Medicare doesn’t cover.
The specifics vary by plan, as private insurers tailor their offerings within Medicare guidelines.
How Does It Work?
• Enrollment: You must already be enrolled in Medicare Parts A and B to join a Part C plan. You sign up through a private insurer, not the government.
• Plan Types: Common options include:
◦ HMO (Health Maintenance Organization): Requires you to use in-network providers and often a primary care doctor for referrals.
◦ PPO (Preferred Provider Organization): Offers more flexibility to see out-of-network providers, though at a higher cost.
◦ SNP (Special Needs Plans): Tailored for people with specific conditions or circumstances (e.g., chronic diseases or nursing home residents).
• Service Delivery: Instead of Medicare paying providers directly (as in Original Medicare), your Part C plan manages your care and payments, often with a network of doctors and hospitals.
Costs
Costs for Medicare Part C vary widely depending on the plan and insurer:
• Premiums: You still pay the Part B premium ($174.70/month in 2024 for most people), plus any additional premium the Part C plan charges (some plans have $0 extra premium).
• Out-of-Pocket Costs: Copays, coinsurance, and deductibles differ by plan. Many plans cap annual out-of-pocket expenses (e.g., $8,850 in-network in 2025), unlike Original Medicare.
• Subsidies: Plans receive funding from Medicare to offer these services, which can lower costs for enrollees compared to buying separate supplemental insurance.
Advantages and Trade-offs
• Pros: Potentially lower costs, added benefits (e.g., dental or vision), and a simplified all-in-one plan.
• Cons: Limited provider networks (especially with HMOs), prior authorization requirements, and less flexibility if you travel or need out-of-network care. Also, benefits and costs can change yearly, requiring you to review your plan.
Enrollment and Eligibility
• Who’s Eligible?: Anyone with Medicare Parts A and B, living in the plan’s service area, can join (except those with End-Stage Renal Disease in some cases, though rules loosened in 2021).
• When to Enroll: Key periods include your Initial Enrollment Period (around your 65th birthday), the Annual Enrollment Period (October 15–December 7 each year), or Special Enrollment Periods (e.g., if you move or lose other coverage).
Summary
Medicare Part C is a private alternative to Original Medicare, combining Parts A and B (and often D) into one plan with potential extras like vision or dental. It’s popular—over half of Medicare beneficiaries were enrolled in Part C plans by 2024—because it can be cost-effective and comprehensive, but it trades some flexibility for those benefits. Your choice depends on your health needs, budget, and preference for managing care through a private insurer versus the government-run system.

03/02/2025

03/02/2025

Medicare Part B is one of the four main components of the Medicare program in the United States, designed to provide health insurance primarily for outpatient services. It’s available to Americans aged 65 and older, as well as certain younger individuals with qualifying disabilities or specific medical conditions, such as End-Stage Renal Disease. Unlike Medicare Part A, which covers inpatient hospital care and is premium-free for most people, Part B is optional and requires a monthly premium.
What Does Medicare Part B Cover?
Medicare Part B focuses on a variety of outpatient and preventive services, including:
• Doctor Visits: Appointments with primary care physicians, specialists, and other healthcare providers.
• Preventive Services: Many services are covered at no cost, such as annual wellness visits, screenings (e.g., for cancer, diabetes, or heart disease), and vaccines (e.g., flu shots).
• Durable Medical Equipment (DME): Medically necessary items like wheelchairs, walkers, and oxygen equipment.
• Outpatient Care: Services such as lab tests, X-rays, outpatient surgeries, and emergency room visits.
• Mental Health Services: Outpatient therapy, counseling, and certain treatments for mental health conditions.
• Ambulance Services: Transportation to medical facilities when medically necessary.
• Certain Prescription Drugs: Drugs administered in a doctor’s office (e.g., chemotherapy or injections), but not most self-administered medications, which are typically covered under Medicare Part D.
Costs Associated with Medicare Part B
Part B involves several out-of-pocket costs:
• Premiums: In 2024, the standard monthly premium is $174.70. However, higher-income beneficiaries may pay more due to the Income-Related Monthly Adjustment Amount (IRMAA), based on their income level.
• Deductible: There’s an annual deductible of $240 in 2024. You pay this amount out-of-pocket before Medicare begins covering Part B services.
• Coinsurance: After meeting the deductible, you typically pay 20% of the Medicare-approved amount for most services. For example, if a doctor’s visit costs $100, you’d pay $20, and Medicare would cover the remaining $80.
Enrollment and Eligibility
• Who is Eligible?: You qualify for Part B if you’re 65 or older, or under 65 with a qualifying disability or condition.
• Initial Enrollment Period (IEP): This is a 7-month window starting three months before your 65th birthday and ending three months after. Enrolling during this period helps you avoid penalties.
• Late Enrollment Penalty: If you delay signing up for Part B when first eligible and lack other creditable coverage (e.g., employer-sponsored insurance), your premium may increase permanently by 10% for each full year you could have enrolled but didn’t.
How Part B Works with Other Insurance
If you have other health insurance, like through an employer, you might delay enrolling in Part B without penalty, provided that insurance is considered creditable. However, you should understand the rules for coordination of benefits and timing to avoid coverage gaps or penalties.
Summary
Medicare Part B is a vital part of Medicare that covers outpatient medical services, preventive care, and certain equipment. While it comes with costs like premiums, deductibles, and coinsurance, it provides essential healthcare coverage. Enrollment decisions should be made thoughtfully, considering your health needs, finances, and any other insurance you may have.