In this article

• Medicare fraud vs. Medicare scams: What’s the difference?
• What are the most common types of Medicare fraud?
• What are the most common types of Medicare scams?
• I gave my Medicare number to a scammer, now what?
• How can I protect myself from Medicare fraud and scams?

Medicare loses an estimated $60 billion each year due to fraud and scams.¹ In Fiscal Year 2024 alone, Medicare paid out $31.70 billion in improper payments, which include fraud, waste, and abuse.²

Healthcare scams cost consumers $17 million in losses in 2023, although the actual figure is estimated to be much higher, as these losses aren’t always reported.³ Health-related scams tend to spike during Medicare Open Enrollment⁴ (October 15 to December 7), when scammers take advantage of consumer confusion and time pressure.³

Healthcare fraud and scams are not the same thing, though both can leave enrollees dealing with financial loss, stress, and hours spent fixing the damage.^{5 6} Here’s the difference between Medicare fraud and Medicare scams, how to protect yourself, and what to do if you think you’ve been targeted.

1. “Dollars Lost to Fraud” Senior Medicare Patrol. Accessed Dec. 20, 2025
2. “Fiscal Year 2024 Improper Payments Fact Sheet” CMS.gov. Accessed Dec. 20, 2025
3. “2024 Fighting Fraud: Scams to Watch Out For” page 55. U.S. Senate Special Committee on Aging. Accessed Dec. 20, 2025
4. “Medicare.gov. Accessed Jan. 14, 2026
5. “Medicare Fraud & Abuse: Prevent, Detect, Report” page 6. CMS.gov. Accessed Dec. 20, 2025
6. “Older Americans and Medicare Call Scams” FCC.gov. Accessed Dec. 20, 2025
7. “Health Care Fraud” FBI.gov. Accessed Dec. 20, 2025
8. “Fraud Schemes” Senior Medicare Patrol. Accessed Dec. 20, 2025
9. “Common Types of Health Care Fraud Fact Sheet” CMS.gov. Accessed Dec. 20, 2025
10. “Protect Yourself from Social Security Scams” SSA.gov. Accessed Dec. 20, 2025
11. “Your Medicare Card” Medicare.gov. Accessed Dec. 20, 2025
12. “Older Americans and Medicare Call Scams | Federal Communications Commission” FCC.gov. Accessed Dec. 20, 2025
13. “eCFR: 42 CFR 422.2264 – Beneficiary contact” ECFR.gov. Accessed Dec. 20, 2025
14. “Consumer Alert: Urinary Catheter Scams” OIG.HHS.gov. Accessed Dec. 20, 2025
15. “Durable Medical Equipment Fraud” Senior Medicare Patrol. Accessed Dec. 20, 2025
16. “Durable Medical Equipment Coverage” Medicare.gov. Accessed Dec. 20, 2025
17. “Genetic Testing Fraud” Senior Medicare Patrol. Accessed Dec. 20, 2025
18. “Beware of a Growing Medicare Scam: “Free Genetic Testing” Senior Medicare Patrol. Accessed Dec. 20, 2025
19. “LCD – BRCA1 and BRCA2 Genetic Testing (L36715)” CMS.gov. Accessed Dec. 20, 2025
20. “LCD – Pharmacogenomics Testing (L39073)” CMS.gov. Accessed Dec. 20, 2025
21. “Monitor Breaches and Watch for Scams” Privacy.ca.gov. Accessed Dec. 20, 2025
22. “CMS Notifies Individuals Potentially Impacted by Data Incident” CMS.gov. Accessed Dec. 20, 2025
23. “Reporting Medicare Fraud & Abuse” Medicare.gov. Accessed Dec. 20, 2025
24. “Medicare Summary Notice (MSN)” Medicare.gov. Accessed Dec. 20, 2025
25. “Credit Freezes and Fraud Alerts” Consumer.FTC.gov. Accessed Dec. 20, 2025
26. “Medicare Scams: How to Protect Yourself” National Council on Aging. Accessed Dec. 20, 2025
27. “Consumer Alerts” OIG.HHS.gov. Accessed Dec. 20, 2025

That does not necessarily mean healthcare for enrollees is inexpensive. Medicare leaves many costs on the table – costs that many enrollees do not plan for and may not even know about. It’s up to you, the savvy consumer, to learn where your dollars will be spent on healthcare as a Medicare beneficiary. As a retiree on a fixed income this becomes more important than ever. The more you know, the better you can plan for your financial future.

General out-of-pocket costs

Most health insurance plans have the following out-of-pocket elements. Medicare also imposes penalties for signing up too late for Part B or Part D. All rates below are for 2026, for Original Medicare¹ (Medicare Advantage plans set their own cost-sharing and premiums, within general parameters established by the federal government).

1. The deductible

This is the amount you will pay out of pocket before Original Medicare starts paying for medical services. These amounts are for 2026:

• Part A (hospital insurance, administered by the federal government): You will pay $1,736 for each benefit period. (A benefit period starts when you’re admitted to the hospital and ends 60 days after you’ve been discharge, assuming you’re not readmitted during that time). You could pay more than one deductible per year based on the timing of any hospitalizations.
• Part B (medical insurance, administered by the federal government): You will pay $283 as the annual deductible in 2026, if you receive services covered by Medicare Part B (other than preventive services that are covered without a deductible;² note that if you receive only a small amount of Part B-covered care and the total bill is less than $283, you will only pay for the care you received, rather than the full deductible)
• Part D (prescription drug coverage, offered by private insurers): Deductibles vary but can be no more than $615 in 2026.³

2. Premiums

This is the amount you pay each month for Medicare, whether or not you use any healthcare services. The following rates are for 2026.

• Part A: Premiums are free if you worked 40 quarters (10 years) in Medicare-taxed employment. They cost $311 or $565 per month if you worked 30-39 or less than 30 quarters respectively.¹
• Part B: All enrollees pay Part B premiums, even if they are enrolled in a Medicare Advantage plan (unless they are eligible for a program that pays some or all of the Part B premium on their behalf). That amount is $202.90 for single individuals earning less than $109,000 or for married individuals with a joint income less than $218,000.¹ (Your income from two years prior is used for this determination.)
• Part D: Premiums vary based on the plan. The national base beneficiary premium (on which late enrollment penalties are based) is $38.99 in 2026.³ As with Part B, premiums are higher for high-income enrollees.

3. Income-Related Monthly Adjustment Amount (IRMAA)

Medicare adds an increased amount to your Part B and Part D premiums based on your annual income. Your federal income taxes from two years prior are used to decide how much you will pay in premium (since these are the most recent tax returns on file; 2024 tax returns are the returns that were filed most recently before the start of the 2026 coverage year).

In 2026, if you earn no more than $109,000 as a single individual or $218,000 as a married couple filing jointly, you will not pay an income-related monthly adjustment amount (IRMAA). If you earn more than those amounts, you’ll pay an IRMAA surcharge, which increases incrementally based on your annual income.⁴

4. Late-enrollment penalties

Medicare requires you to enroll in the program within designated periods. Otherwise, you will face late penalties that are added to your monthly premium.

• Part A: You will pay 10% of your monthly premium for twice the number of years you were eligible but did not enroll in Medicare Part A. (If you sign up two years late, you will pay a penalty for four years.) This penalty only applies to late enrollees who have to pay a premium for Part A; 99% of Medicare enrollees pay no premium for Part A.⁴
• Part B:You will pay 10% of your monthly premium times the number of years you went without Medicare Part B coverage. (If you sign up two years late, you will pay 20% more on your premiums every year.) This penalty lasts as long as you have Medicare coverage. If you delay Part B because you’re continuing to work and have employer-sponsored health insurance as an active employee (or spousal coverage under your spouse’s active employee coverage), you will not have a late enrollment penalty if you sign up for Part B when you eventually stop working.
• Part D:You will pay 1% of the national base beneficiary premium, which increases every year, multiplied by the number of months you were eligible but didn’t sign up.⁵
• Like Part B, this is a life-long penalty. The national base beneficiary premium is a standard rate set by the federal government to calculate Part D penalties, and it changes each year⁶ (it will likely not be the same as your actual Part D plan premium). If you delay Part D enrollment because you’re covered under another plan that provides creditable drug coverage (meaning the plan meets or exceeds Medicare’s minimum drug coverage requirements), you won’t be subject to the late enrollment penalty.

5. Copays and coinsurance

This is the fixed amount or percentage amount, respectively, that you pay for each Medicare-covered service or medication, after you’ve paid any applicable deductible (for the benefit period or year, depending on which part of Medicare is being used).

• Original Medicare (Costs are for 2026)
  • Part A: After 60 days in a hospital, Medicare charges a coinsurance of $434 per day for days 61 to 90. Refer to lifetime reserve days below for days 91+. After 20 days in a skilled nursing facility, coinsurance costs $217 per day for days 21 to 100. After 100 days, you pay all costs out of pocket.¹⁴Medicare does not cover long-term custodial care, but beneficiaries who need long-term care may consider applying for Medicaid, which does cover custodial care for eligible enrollees. (Here’s state-by-state information on eligibility rules for Medicaid, which is available to people with limited financial means.)
  • Part B: For most covered services, you’ll pay 20% of the Medicare-approved amount, although certain preventive screening tests will be covered in full. If your doctor doesn’t “accept assignment” (see below under provider-based expenses), you may have to pay up to 15% more for the medical care your receive.
• Medicare Advantage (Part C): Medicare Advantage plans cover all of the services that are covered by Part A and Part B but have their own cost-sharing structure that may differ from Original Medicare (federally administered Part A and Part B).
• Part D: Copays and coinsurance vary based on the plan. Generally speaking, costs may be higher for certain brand-name or more expensive medications. Keep in mind that you may have to pay the full cost out of pocket if a medication is not on your plan’s formulary (covered drug list). This makes it particularly important that you actively compare the available drug plans each year during the annual open enrollment window (October 15 to December 7), and see how they’ll cover the specific medications you need and the pharmacies you use.

6. Non-covered services

Medicare typically provides broad coverage but does not cover everything.⁷ Original Medicare, for example, does not cover routine dental care, dentures, routine eye care, corrective lenses, dentures, hearing aids, or long-term nursing home care.

Coverage is also limited for acupuncture⁸ (meaning you must meet specific criteria for low back pain) and cosmetic surgery⁹ (meaning you must have a medical indication for the surgery).

Provider-based expenses

Your out-of-pockets are directly affected by the healthcare provider you see. Make sure you take these factors into consideration before you schedule any appointments.

7. Doctors that don’t participate in Medicare

Not every doctor agrees to accept Medicare for payment.¹⁰ This can be tricky when you need to see a specialist and there are few in your area. Providers who opt out of Medicare do not accept Medicare patients but could sign a private contract with you. Those contracts will vary but will likely leave you to pay more than you would have if the doctor had not opted out of Medicare.

8. Doctors that don’t accept assignment

These doctors do accept Medicare for payment but they do not accept assignment,¹¹ meaning that they do not agree to Medicare’s standard rates for their services. In order to participate in the Medicare program, however, they agree to not charge more than 15% above Medicare’s approved rates, for most services covered by Medicare. (The charge cap does not apply to some medical supplies and durable medical equipment.) This additional amount is known as the limiting charge, and some states restrict it to a smaller amount.¹²

If you see a doctor who has not opted out of Medicare but who does not accept assignment, you’ll be responsible for paying the limiting charge unless you have supplemental coverage that pays it (for example, an employer-sponsored plan or Medigap plan F or G).¹³

9. Doctors outside of your Medicare Advantage plan network

Original Medicare has a nationwide network of providers, meaning you can see any doctor that takes Medicare. The same is not true for Medicare Advantage.

Medicare Advantage plans are built on a local network of providers. If a doctor takes Medicare but is not in your Medicare Advantage plan’s network, your plan could require you to pay more in cost-sharing for any medical services received. Some Medicare Advantage plans will not cover any non-emergency care unless you see in-network providers, so be sure you understand your plan’s rules for this.

If your Medicare Advantage plan is a PPO that covers out-of-network medical care, your combined in-network and out-of-network out-of-pocket charges can’t exceed $13,900 in 2026 (not counting prescription drug charges).¹⁴

Hospital-based expenses

10. Inpatient vs. observation stays

Staying overnight in a hospital does not necessarily mean you are admitted as an in-patient. You pay for inpatient hospital stays with a Part A deductible (and for any physician services you receive while in the hospital, you’ll pay the Medicare Part B deductible if you haven’t already met it earlier in the year, plus a 20% Part B coinsurance).

When you are placed under observation, Part B provides your only coverage, as observation is considered outpatient care. You are responsible for the Part B deductible plus 20% of the cost of any services you receive.

This adds up and explains why observation stays often cost more than inpatient stays, even if the care is the same. (Note that Medigap coverage will pay some or all of the 20% coinsurance for Part B services).

11. Lifetime reserve days

After spending 90 days in a hospital within a single benefit period, you have 60 lifetime reserve days to use. These days cost you $868 each in 2026 and extend coverage for your hospital stay for days 91 onward.¹ After you use up those 60 days – the only ones you will ever get – Medicare stops paying for extended days altogether.

12. Skilled nursing facility three-day rule

When you leave a hospital, you may be too sick to go home. Medicare will only cover a short-term stay in a skilled nursing facility (SNF) for rehabilitation if you were in the hospital for three days as an inpatient, not counting the day you were transferred to the SNF. If your hospital stay does not meet those requirements, you could be left to pay for your SNF stay on your own. ¹⁵

Medicare Advantage plans can opt out of this rule and could potentially provide SNF coverage after a shorter inpatient stay. Additionally, certain Accountable Care Organizations (ACOs) can apply for a waiver of the three-night rule.

Medicare Advantage and Part D expenses

Certain out-of-pocket costs are specific to Medicare Advantage and Part D plans.

13. Maximum out-of-pocket limits

Original Medicare has no cap on out-of-pocket expenses. CMS, however, sets a cap on expenses known as the Maximum Out of Pocket Limit (MOOP) for Medicare Advantage plans. Only services also covered by Original Medicare (Parts A and B) are considered in the MOOP, so prescription drug charges will be counted separately under the Medicare Advantage plan’s integrated Part D benefit.

In 2026, the Medicare Advantage maximum out-of-pocket cap for in-network care cannot be more than $9,250, and the combined in-network and out-of-network out-of-pocket cap for PPOs can’t be more than $13,900.¹⁴ With that in mind, know that Medicare Advantage plans that cover out-of-network care often have a prior authorization requirement for out-of-network coverage, so be sure you understand your plan’s requirements before obtaining any non-emergency services.

14. Medicare Part D out-of-pocket costs

The Inflation Reduction Act (IRA) has had a significant impact on what Medicare enrollees pay for prescription drugs, whether through a stand-alone Part D plan (PDP) or a Medicare Advantage plan with Part D coverage (MA-PD).

Starting in 2025, the IRA imposed a $2,000 cap on enrollees’ out-of-pocket spending for covered drugs. This amount is adjusted annually for inflation, and climbed to $2,100 for 2026.³ The out-of-pocket cap includes the deductible (which can’t be more than $615 in 2026),³ but does not include the cost of your monthly premiums.¹⁶

Before the IRA reformed Part D coverage, as many as 20% of Medicare beneficiaries struggled to afford their medications once they reached what was known as the donut hole, a coverage gap in Part D plans. ¹⁷ As a result, cost-sharing is more predictable and simplified: There’s a deductible phase (if the plan has a deductible), and then coverage and cost-sharing are consistent until the enrollee reaches the out-of-pocket cap. At that point, the enrollee has no more out-of-pocket costs for covered drugs for the rest of the year.

Knowing the maximum you will pay for drug costs offers another benefit. The IRA added an option to spread your drugs costs out over the year rather than paying those costs upfront earlier in the year. This may make it easier for you to budget during the year.¹⁸

Tanya Feke, M.D. is a licensed, board-certified family physician living in New Hampshire. As a practicing primary care physician in Connecticut and an urgent care physician in New Hampshire, she saw first-hand how Medicare impacted her patients. In recent years, her career path has shifted to consultant work with a focus on utilization management and medical necessity compliance.

Dr. Feke is an expert in the field, having Medicare experience on the frontlines with patients, hospital systems, and insurers. To educate the public about ongoing issues with the program, she authored “Medicare Essentials: A Physician Insider Reveals the Fine Print.” Her analysis of Medicare issues is frequently referenced by the media, and she is a contributor to multiple online publications.

1. “Costs” Medicare.gov. Accessed Dec. 4, 2025
2. “Preventive & screening services” Medicare.gov. Accessed Dec. 4, 2025
3. “How much does Medicare drug coverage cost?” Medicare.gov. Accessed Dec. 4, 2025
4. “2026 Medicare Parts A & B Premiums and Deductibles” Centers for Medicare & Medicaid Services. Nov. 14, 2025
5. “Part D late enrollment penalty” Medicare.gov. Accessed Dec. 4, 2025
6. “A Current Snapshot of the Medicare Part D Prescription Drug Benefit” KFF.org. Oct. 7, 2025
7. “What’s not covered?” Medicare.gov. Accessed Dec. 4, 2025”
8. “Acupuncture” Medicare.gov. Accessed Dec. 4, 2025”
9. “Cosmetic surgery” Medicare.gov. Accessed Dec. 4, 2025”
10. “Does your provider accept Medicare as full payment?” Medicare.gov. Accessed Dec. 4, 202
11. “Does your provider accept Medicare as full payment?” Medicare.gov. Accessed Dec. 4, 2025”
12. “Does your provider accept Medicare as full payment?” Medicare.gov. Accessed Dec. 4, 2025
13. “Compare Medigap Plan Benefits” Medicare.gov. Accessed Dec. 4, 2025
14. “Final Contract Year (CY) 2026 Standards for Part C Benefits, Bid Review and Evaluation” Centers for Medicare & Medicaid Services. Apr. 16, 2025
15. “Skilled nursing facility care” Medicare.gov. Accessed Dec. 4, 2025”
16. “ Announcement of Calendar Year (CY) 2025 Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies” CMS.gov. April 1, 2024
17. “Financial hardship from purchasing prescription drugs among older adults in the United States before, during, and after the Medicare Part D “Donut Hole”: Findings from 1998, 2001, 2015, and 2021” National Library of Medicine. May 202efn_note] The IRA eliminated the donut hole starting in 2025.[efn_note]“CMS Releases 2025 Medicare Part D Bid Information and Announces Premium Stabilization Demonstration” Centers for Medicare & Medicaid Services. Jul. 29, 2024
18. “What’s the Medicare Prescription Payment Plan?” Medicare.gov. Accessed Dec. 4, 2025

In this article

• Continuing to work after you’re eligible for Medicare?
• Individual/family health coverage
• Coverage through your spouse’s employer-sponsored plan
• Retiree health benefits from your former employer
• Temporary coverage through COBRA
• Medicaid or CHIP

When you turn 65 and transition to Medicare, what sort of health coverage is available for your family? You’re not the first person to have this question.

Most people are accustomed to health coverage – often provided by an employer¹ – that covers the whole family under one policy. But Medicare only provides individual coverage. (Even if two spouses are both enrolled in Medicare, they each have their own individual plan.)

That means your family will need separate coverage, as you can’t add them to your Medicare policy. The good news is that coverage is available to meet your family’s needs, and they’ll be able to transition to new plans, if necessary.

Continuing to work after you’re eligible for Medicare?

If you’re continuing to work after you turn 65 and your employer-sponsored health insurance plan covers your family, you won’t need to make any changes to their coverage until you retire or lose access to the employer-sponsored plan. Depending on the circumstances, you’ll likely be enrolling in at least Medicare Part A² (or possibly Part A and Part B) in addition to your employer’s plan.

(The decision there hinges on the size of the employer: If the employer has 20 or more employees, the group plan will be your primary coverage and Medicare will be secondary. Most people in this situation choose to delay enrollment in Part B until they stop working. But if the employer has fewer than 20 employees, Medicare will provide primary coverage and employees need to enroll in both Part A and Part B when they’re initially eligible.)

But if and when your family no longer has access to the same coverage they had before you transitioned to Medicare, there are several options to keep in mind:

Individual/family health coverage

If you’re retiring and will no longer have access to an employer’s health plan, your family will have the option to obtain their own health insurance in the individual/family market. They can buy a plan in your state’s Marketplace/exchange – or directly from an insurance company, but financial assistance is not available for plans purchased outside the exchange.

There’s an annual open enrollment period for individual/family health coverage, but if your retirement means that your family will lose coverage that was provided by your employer, they’ll probably be eligible for a special enrollment period.

Plan availability in the health insurance Marketplace varies from one area to another. You might see 10 or 20 options, or you might see several dozen choices. There are local assisters who can provide plan information and help you choose coverage, but we’ve also got an explainer with the main points to keep in mind when you’re comparing various plan options.

Depending on the availability of other employer-sponsored coverage (which we’ll get to in a moment), your household’s income, your zip code, and the age of the family members who will need to purchase coverage, premium tax credits (premium subsidies) may be available. Those tax credits have been larger and more widely available from 2021 through 2025, as a result of the American Rescue Plan and Inflation Reduction Act, but it would take another act of Congress to extend the subsidy enhancements into 2026 (that had not yet happened as of early December 2025).³ Marketplace subsidies will continue to be available either way, but they’ll be smaller and available to fewer people if Congress doesn’t extend the enhancements.

In addition to premium subsidies, if the household’s income doesn’t exceed 250% of the poverty level, cost-sharing reductions⁴ (discounts that lower the amount you pay for deductibles, copays, and coinsurance) will also be included on some of the available plans.

You can use our subsidy calculator to quickly estimate how much your household’s subsidy will be, based on income, enrollees’ ages, and zip code. It’s useful to understand what counts as income under the Affordable Care Act (ACA), since it’s an ACA-specific version of modified adjusted gross income that isn’t used for other purposes (other MAGI calculations, such as MAGI used to determine whether a tax filer is eligible for the child tax credit, use a different methodology).⁵

Keep in mind that the whole household’s income is taken into consideration, including any income earned by the family member who is transitioning to Medicare. This is also important to understand if your family already has a plan through the Marketplace and they will remain on it after you transition to Medicare. The dynamics of how premium subsidies might change in this circumstance are illustrated in this example.

Coverage through your spouse’s employer-sponsored plan

If your spouse’s employer offers health benefits and your family will be losing the coverage you had through your employer, transitioning them to your spouse’s employer-sponsored health plan is an option to consider. As is the case for individual/family coverage in the Marketplace, there will be a special enrollment period with your spouse’s employer due to the loss of coverage through your employer.

If coverage is available through your spouse’s employer and it’s considered affordable and provides minimum value, premium tax credits would not be available for individual/family coverage purchased in the Marketplace. It’s important to understand how the “family glitch” fix works, in terms of how affordability determinations are made for family members. Learn more about how affordability and minimum value are determined for employer-sponsored coverage.

Retiree health benefits from your former employer

If your former employer offers retiree health benefits that include family coverage, that may be a good option for your family. You’ll want to consider the cost and the benefits and compare them with the cost and benefits of plans that are available in your state’s individual/family Marketplace.

Unlike an offer of coverage from a current employer, an offer of retiree health benefits does not make a household ineligible for premium tax credits in the Marketplace, regardless of the cost of the retiree health benefits. So if your household would be eligible for premium tax credits in the Marketplace, you can compare the retiree health benefits with the subsidized cost of individual/family coverage when you’re considering the options.

Temporary coverage through COBRA

If COBRA or state continuation (“mini-COBRA,” available in many states if you worked for a small employer) coverage is an option, it may work well as temporary coverage for your family members once you transition to Medicare. COBRA coverage is normally available for up to 18 months, although state continuation rules vary from one state to another.

If you’re retiring and you became eligible for Medicare no more than 18 months ago, your spouse and dependents can potentially use COBRA coverage for up to 36 months from the time you became eligible for Medicare. (This is only applicable if you became eligible for Medicare before retiring; if your retirement date and COBRA eligibility date are the same, your spouse and dependents will only have access to 18 months of COBRA.)

Electing COBRA or state continuation coverage means that your family will not have to deal with changing to a new health plan, at least for the duration of coverage through COBRA. This can be beneficial in situations where a person is in the middle of a course of treatment or has already spent a considerable amount of money towards their out-of-pocket costs for the year.

COBRA and state continuation coverage require you to pay the full cost of the premiums, including the portion that your employer was previously paying, plus an administrative fee (2% for COBRA, although it varies for state continuation coverage).

Medicaid or CHIP

Depending on your household’s income, your family members may be eligible for Medicaid or CHIP. In the majority of the states, adults under the age of 65 are eligible for Medicaid if the total household income doesn’t exceed 138% of the federal poverty level. For a household of three in the continental U.S., that amounts to about $3,065 in monthly income in 2025. For dependents up to the age of 18, Medicaid and CHIP eligibility extends to higher income levels.

The short story? Your family will be able to obtain health coverage after you transition to Medicare. Depending on the circumstances, they might have multiple options from which to choose. And help is available too, from your employer’s HR department or benefits broker, or from a licensed insurance broker or navigator who can help you figure out the best individual/family plan to fit your needs, or assist with enrollment in Medicaid or CHIP.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written hundreds of opinions and educational pieces about the Affordable Care Act and Medicare for healthinsurance.org and medicareresources.org.

1. “Employer-Sponsored Health Insurance 101” KFF.org. Oct. 8, 2025
2. “What Part A Covers” Medicare.gov. Accessed Dec. 2, 2025
3. “GOP pessimism grows over any deal to extend expiring health care subsidies” The Hill. Dec. 2, 2025
4. “Cost-sharing reductions” HealthCare.gov. Accessed Dec. 2, 2025
5. “Modified adjusted gross income” Internal Revenue Service. Accessed Dec. 2, 2025

In this article

• Part D out-of-pocket costs capped
• Full Extra Help available to more Medicare Part D enrollees
• How Part D premiums and plan availability have changed under the IRA
  
• IRA provisions focused on reducing drug costs
• Capped insulin copays and zero-cost vaccines continue

The Inflation Reduction Act, enacted in 2022, has been phasing in various changes to Medicare drug coverage – mostly Part D, but also Part B, as discussed below. Here’s where enrollees are most likely to see their costs and benefits affected by the IRA:

Part D out-of-pocket costs capped

One of the most highly anticipated IRA improvements took effect in 2025: A $2,000 cap on out-of-pocket costs under Medicare Part D (including stand-alone Part D plans and Part D coverage integrated with Medicare Advantage plans), which is indexed in subsequent years. (For 2026, the cap is $2,100.)¹ The cap includes the deductible² and any copays or coinsurance that enrollees pay for drugs that are covered by their plan.

Starting in 2024, the IRA had eliminated Part D out-of-pocket costs for covered drugs once an enrollee reached the catastrophic coverage level. That effectively implemented an out-of-pocket limit of roughly $3,300.³ Before 2024, enrollees paid 5% of the cost of covered drugs once they reached the catastrophic coverage level, and there was no limit on how high out-of-pocket costs could be under Medicare Part D. About 1.5 million Medicare Part D enrollees had prescription drug costs that put them above the catastrophic coverage level in 2019.⁴

The Medicare Part D “donut hole” was also eliminated as of 2025 by the IRA, making prescription drug cost-sharing more simplified. As a result of the IRA, Part D coverage now includes only a deductible phase (if the plan has a deductible), an initial coverage phase until the enrollee reaches the out-of-pocket cap ($2,100 in 2026), and then a catastrophic coverage phase under which covered drugs have no cost-sharing (meaning the enrollee doesn’t have to pay anything to fill covered prescriptions for the rest of the year).⁵

Starting in 2025, people with Medicare Part D have the option to spread their out-of-pocket costs across the full year. Enrollees can opt into this by contacting their Part D plan, and will then be able to pay their out-of-pocket costs in equal monthly payments, instead of having to meet their out-of-pocket limit early in the year.⁶ This is detailed in Section 11202 of the Inflation Reduction Act.

Full Extra Help available to more Medicare Part D enrollees

Medicare’s Extra Help program (also known as the Low-Income Subsidy) provides financial assistance that can make prescription drugs and Medicare Part D prescription drug (Part D) premiums more affordable for policyholders.

Before 2024, people eligible for Extra Help could either qualify for full Extra Help (with income up to 135% of the federal poverty level, or FPL) or partial Extra Help (with income between 135% and 150% of FPL. Partial Extra Help offset some costs, but did not provide as much financial assistance as full Extra Help.⁷

Starting in 2024, under the IRA, full Extra Help became available to enrollees with income up to 150% of the federal poverty level (FPL), as long as their assets were within the eligible range. So partial Extra Help is no longer used: Anyone who qualifies for Extra Help is getting the full benefit.

For 2025, the income limit for Extra Help eligibility in the continental U.S. is $23,475 for a single person or $31,725 for a married couple.⁸ These limits will increase in early 2026 to keep pace with the updated FPL numbers for 2026.

In 2025, the asset limit is $17,600 for a single individual or $35,130 for a married couple; these limits are indexed each year. Some assets are not counted, such as your primary home and your vehicles.⁸

According to the U.S. Department of Health and Human Services, the eligibility expansion for full Extra Help made the full benefits newly available to 300,000 people starting in 2024. These enrollees save an average of $300 per year due to the additional financial assistance provided by full Extra Help.⁹

Know someone who might be eligible for Extra Help? The Social Security Administration has information about how that person can apply for this benefit.

Learn more about Extra Help.

How Part D premiums and plan availability have changed under the IRA

Overall, the average premium for a stand-alone Part D plan (PDP) was $41.63/month in 2024, and was projected to decrease slightly, to $40/month, in 2025.¹⁰ But there are fewer stand-alone Part D plans available in 2025: There were a total of 709 Part D plans available across the country in 2024, and that dropped to 524 plans in 2025.¹¹

Since the IRA is shifting more drug costs onto Part D plans, there were concerns that premiums might increase significantly or plans might exit the market in 2025. So CMS introduced a one-year premium stabilization program for stand-alone Medicare Part D plans.¹²

The program gives participating insurers $15/month for each enrollee, to offset what would otherwise have been higher premiums for enrollees. Participating insurers had to limit 2025 premium increases to no more than $35/month. CMS noted that 99% of people with stand-alone Part D plans are in plans that have opted into the premium stabilization program, and average stand-alone Part D premiums decreased slightly for 2025.¹⁰ But a KFF analysis indicates that many participating insurers imposed a rate increase of exactly $35/month.¹¹

The projected $40/month average premium for stand-alone Part D plans in 2025 is similar to what average premiums had been in the several years before the IRA was enacted.¹³

One of the provisions under the IRA that impacted Part D premiums starting in 2024 was the capping of Medicare Part D national base beneficiary premium (NBBP) that took effect in 2024. (The NBBP is calculated by the federal government, based on bids submitted by plans and a formula that’s set in statute; starting with the 2024 plan year, that formula changed to include the cap set by the IRA.)

This cap limits the NBBP to no more than 6% higher than it was the year before. But while consumers may expect the IRA’s cap to directly limit how much their Part D premiums increase, it’s more complicated than that:

1. The base beneficiary premium isn’t the only factor affecting Part D premiums – it’s just the starting point.¹⁴ Plan-specific premiums for basic coverage are calculated by adjusting the NBBP by how much the plan’s bid amount differs from the national average bid. (So if the plan’s bid is lower than the national average bid, the plan-specific basic premium will be lower than the NBBP, and if the plan’s bid is higher than the national average bid, the plan-specific basic premium will be higher than the NBBP). And for plans with supplemental/enhanced benefits, the additional supplemental premium is then added to get the total premium.¹⁵ So while the base beneficiary premium for 2024 was 6% higher than it was in 2023, a specific plan’s rate increase could still be much more significant. For more information, this brief from CMS explains how the base beneficiary premium is used to calculate plan-specific premiums for each plan’s basic benefit.
2. Though CMS announced that average total Part D premiums (including basic and supplemental benefits) would be slightly lower in 2024 than in 2023, those decreases were an average. We saw significant rate changes – both increases and decreases – for some plans.¹⁶For 2025, average total Part D premiums are again decreasing, from $53.95 in 2024 to $46.50 in 2025.¹⁰ But there will still be a wide range of plans available, with a wide range of premiums.
3. There is also tremendous variation from one Part D plan to another: For the 2024 plan year, premiums for stand-alone Part D plans ranged from $0/month to over $100/month. The number of enrollees paying $0/month was roughly the same as the number of enrollees paying at least $100/month.¹⁷ So averages don’t tell the whole story. And although average Part D premiums decreased slightly for 2025, there continues to be a lot of variation from one plan to another, both in terms of total premiums and premium changes for 2025.¹¹

So although there is now a cap on the NBBP, enrollees should know that actual premium changes – increases or decreases – for a specific plan can still be much larger than 6%. So enrollees must compare all of the plan options that are available to them during open enrollment each fall.

(It’s also important to note that the Part D late enrollment penalty is based on the national base beneficiary premium. So the cap on the base beneficiary premium means that people who pay a Part D late enrollment penalty are paying a slightly smaller penalty in 2024 and future years than they would have paid without that cap.)

IRA provisions focused on reducing drug costs

In addition to addressing out-of-pocket costs and premiums for Medicare Part D, the IRA also included provisions to address the amount that beneficiaries, the government, and insurers pay for prescription drugs covered by Medicare Part D and Part B.

Medicare Prescription Drug Inflation Rebate Program

Since the start of 2023, the IRA has been requiring prescription drug manufacturers to pay rebates to Medicare if the price of their drugs increases faster than inflation.¹⁸ The Department of Health and Human Services will start to send rebate invoices to drug manufacturers in 2025.

And, since April 2023, Medicare Part B enrollees who use certain medications may have seen reduced cost-sharing/coinsurance for drugs whose prices have increased faster than inflation.¹⁹

The list of drugs with reduced coinsurance changes each quarter. As of the first quarter of 2025, there were 64 prescription drugs covered under Medicare Part B that have reduced cost-sharing as a result of the IRA’s Inflation Rebate Program.²⁰ But as of the fourth quarter of 2024, there were only 54 drugs on the list.²¹

For those drugs, the Medicare Part B coinsurance rate is lower than the 20% that normally applies to services covered under Part B. (Part B-covered drugs are certain drugs that are administered in a medical office by infusion or injection; most drugs are covered under Part D instead, and are not affected by this program.)²²

If a beneficiary has supplemental coverage – from Medicaid, Medigap, or an employer’s health plan – that pays their Part B coinsurance, they won’t notice a difference. But if a beneficiary pays their own Medicare Part B coinsurance and uses a drug that’s subject to the rebates, they will notice lower out-of-pocket costs.

A similar rebate system already operates in the Medicaid program, and plays a significant role in keeping drugs costs lower for Medicaid.

Medicare drug price negotiation underway; lower costs begin in 2026

As a result of the IRA, Medicare can negotiate pricing with drug manufacturers – something that was previously forbidden. The price negotiations apply to a fairly small subset of drugs. But they are some of the most expensive drugs, and relatively few drugs account for the majority of Medicare’s drug spending. The first year of negotiated rates, applicable to 10 drugs, will be 2026. But the process began in 2023.

In September 2023, HHS published a list of ten Part D drugs that would be subject to negotiation (selected from among the 50 qualifying drugs with the highest spending; various rules apply here, including the fact that the drugs must have been on the market for several years and not have generic alternatives).

HHS then negotiated with the drug manufacturers, following the protocol outlined in the IRA. And in August 2024, HHS published the negotiated prices that will take effect in 2026 for those ten drugs. In January 2025, HHS published the list of 15 additional drugs – including three drugs that can be used for weight loss in certain patients – that will be subject to price negotiations that will take effect in 2027.²³

This process will continue for each of the next few years, with additional drugs added to the negotiation process for 2028 and 2029. Another 15 drugs will be added for 2028, and 20 more will be added for 2029. So by that point, there will be 60 drugs subject to negotiation, all of which will be among the most expensive drugs that don’t have generic alternatives. In the latter two years, the newly added drugs will potentially be a mix of Part D and Part B drugs, whereas the negotiated rates in 2026 and 2027 will all apply to Part D drugs.

Drug manufacturers that do not comply with the negotiation process will be subject to financial penalties. Alternatively, they can choose to no longer have their drugs covered under the Medicare and Medicaid programs.

Capped insulin copays and zero-cost vaccines continue

In addition to those changes, several provisions of the IRA reduced costs for many Medicare beneficiaries starting in 2023 and continue to benefit enrollees in 2025 and future years:

• All insulin products covered by Part D plans now have copays capped at $35. This also applies to insulin covered by Part B, for use in insulin pumps²⁴ (Part B operates with a coinsurance system rather than a copay system, but the coinsurance for insulin cannot exceed $35 per month). CMS has a list of frequently asked questions about the $35 insulin cost-sharing cap.
• If your Part D plan has a deductible, the deductible does not apply to insulin. For insulin covered under Part B, for use in insulin pumps, the Part B deductible does not apply.²⁴
• Vaccines recommended by the ACIP (Advisory Committee on Immunization Practices) covered by Medicare Part D – including Tdap, hepatitis A, hepatitis B (for low-risk individuals), shingles, and RSV – have no out-of-pocket costs (the RSV vaccine for older adults was approved in 2023, and is covered by Part D plans without cost-sharing;²⁵ Tdap, Hep A and B, and shingles vaccines were already covered by Part D plans before the IRA, but often with copays and deductibles; the IRA eliminated the cost-sharing). Vaccines for flu, COVID, pneumonia and hepatitis B (for medium/high-risk individuals) were already covered under Medicare Part B with no out-of-pocket cost and that continues to be the case.²⁶

Note that GLP-1 receptor agonists are not insulin and are thus not subject to the IRA’s insulin price cap. Here’s more about Medicare coverage of GLP-1s.

Note also that Part D plans still have formularies that determine which insulin products they cover; different plans will cover different insulins. If your plan doesn’t cover a particular insulin, you would have to pay full price for it, and it would not count toward your out-of-pocket cap. You can ask your doctor to prescribe an insulin that is covered by your plan, and also know that you can switch to a different Part D plan during the open enrollment period if it would better meet your needs.

Don’t pass on the opportunity to review your Part D costs

Medicare’s open enrollment period runs from October 15 to December 7. If you’re enrolled in Medicare, this is your opportunity to make a change to your Part D coverage, either under a stand-alone Part D plan (PDP) or a Medicare Advantage plan that includes Part D coverage (MA-PD).

And if you have a Medicare Advantage plan – most of which have integrated Part D coverage – you also have a chance to make one plan change during the Medicare Advantage Open Enrollment Period (MAOEP), which runs from January through March each year.

Even if you’re happy with your current drug coverage, it’s worth your while to compare the available options for the coming year. Make sure you know how much your premium will be changing in January and whether your plan will make changes to its cost-sharing or deductibles. You’ll also want to understand what your costs might be under the other plans that are available in your area.

And if you’re enrolled in a Medicare Advantage plan as of January, the MAOEP allows you to make a change to your coverage if the plan you have won’t meet your needs for the rest of the year.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written hundreds of opinions and educational pieces about the Affordable Care Act and Medicare for healthinsurance.org and medicareresources.org. The views expressed in this article are those of the author and may not reflect those of medicareresources.org, which is owned by Healthinsurance.org, LLC.

1. “How much does Medicare drug coverage cost?” Medicare.gov. Accessed Dec. 4, 2025
2. “August 11 Web Event: Understanding the Health Care Provisions in the Inflation Reduction Act” KFF.org. Aug. 11, 2022
3. “An Overview of the Medicare Part D Prescription Drug Benefit” KFF.org. Oct. 17, 2024
4. “Millions of Medicare Part D Enrollees Have Had Out-of-Pocket Drug Spending Above the Catastrophic Threshold Over Time” KFF.org, July 23, 2021
5. “CMS Releases 2025 Medicare Part D Bid Information and Announces Premium Stabilization Demonstration” Centers for Medicare & Medicaid Services. Jul. 29, 2024
6. “Fact Sheet: Medicare Prescription Payment Plan Final Part One Guidance” and “Medicare Prescription Payment Plan Implementation Timeline” Accessed July 22, 2024
7. “What You Need To Know About Extra Help With Medicare Prescription Drug Plan Costs” Social Security Administration. Accessed Dec. 4, 2025
8. “Medicare’s Extra Help Program” Medicare.gov. Accessed Dec. 4, 2025
9. “2021–2024 CMS Accomplishments” (page 10) Centers for Medicare & Medicaid Services. Accessed Dec. 4, 2025
10. “Medicare Advantage and Medicare Prescription Drug Programs to Remain Stable as CMS Implements Improvements to the Programs in 2025” CMS Newsroom. Sep. 27, 2024
11. “Medicare Part D Premiums Are Increasing for Many But Not All Stand-Alone Plans in 2025, Reflecting Effects of New Premium Stabilization Demonstration” KFF.org. Oct. 3, 2024
12. “CMS Releases Preliminary 2025 Medicare Part D Bid Information and Announces Premium Stabilization Demonstration” CMS Newsroom. July 29, 2024
13. “Key Facts About Medicare Part D Enrollment and Costs in 2023” KFF.org, July 26, 2023
14. “42 CFR § 423.286 – Rules regarding premiums” Cornell Law School, Legal Information Institute, Accessed September 2023
15. “CMS Releases 2024 Projected Medicare Part D Premium and Bid Information” Centers for Medicare and Medicaid Services. July 31, 2023
16. “Medicare Part D in 2024: A First Look at Prescription Drug Plan Availability, Premiums, and Cost Sharing” KFF.org. Nov. 8, 2023
17. “Key Facts About Medicare Part D Enrollment, Premiums, and Cost Sharing in 2024” KFF.org, July 2, 2024
18. “How has the Inflation Reduction Act affected Medicare enrollees?” medicareresources.org, Nov. 17, 2025
19. “Fact Sheet: Medicare Prescription Drug Inflation Rebate Program Part B Rebatable Drug Coinsurance Reduction” CMS.gov, March 2023
20. “HHS Announces Cost Savings for 64 Prescription Drugs Thanks to the Medicare Prescription Drug Inflation Rebate Program Established by the Biden-Harris Administration’s Lower Cost Prescription Drug Law” and “Fact Sheet: Reduced Coinsurance for Certain Part B Rebatable Drugs Under the Medicare Prescription Drug
    Inflation Rebate Program” CMS.gov. Jan. 1 – Mar. 31, 2025
21. “Reduced Coinsurance for Certain Part B Rebatable Drugs Under the Medicare Prescription Drug Inflation Rebate Program” CMS.gov. October 1 – December 31, 2024
22. “Prescriptions drugs (outpatient)” Medicare.gov, Accessed October 2024
23. “HHS Announces 15 Additional Drugs Selected for Medicare Drug Price Negotiations in Continued Effort to Lower Prescription Drug Costs for Seniors” CMS.gov. Jan. 17, 2025
24. “Billing Medicare Part B for Insulin with New Limits on Patient Monthly Coinsurance” CMS.gov. February 2024
25. “Respiratory Syncytial Virus (RSV) Shot” Medicare.gov. Accessed Oct. 10, 2024
26. “Search for vaccines” Medicare.gov, Accessed September 2023

The answer depends on a variety of factors, including the coverage you have, the Medicare plans that are available in your area, and certain life circumstances that you might experience.

Medicare open enrollment – also known as Medicare’s Annual Election Period – allows you to enroll in or drop a stand-alone Medicare Part D prescription drug plan (PDP), switch from one PDP to another, switch from Original Medicare to Medicare Advantage or vice versa, or switch from one Medicare Advantage plan to another. Any changes you make during open enrollment will take effect January 1.

Can I change my Medicare Advantage coverage if I missed Medicare open enrollment?

If you have a Medicare Advantage plan, but missed your opportunity to change your coverage during Medicare open enrollment, you’ve got another chance to make a plan change during the Medicare Advantage Open Enrollment Period (MAOEP), which runs from January 1 through March 31.

During that three-month period, you can make one plan change – either switching to a different Medicare Advantage plan or switching to Original Medicare. (In the latter case, you can also enroll in a PDP, but your eligibility to enroll in a Medicare supplemental insurance (Medigap) plan might depend on factors such as your medical history, where you live, and how long you’ve been enrolled in Medicare Advantage.)

Additionally, if there is a 5-star Medicare Advantage plan available in your area, you can switch to that plan at any time between December 8 and November 30.

Read our overview of Medicare star ratings.

Can I make Medicare Part D plan changes if I missed Medicare open enrollment?

After December 7, your opportunity to make changes to your PDP coverage tends to be quite limited. There is nothing comparable to the MAOEP for people who have Original Medicare plus stand-alone Medicare Part D coverage.

If you’re enrolled in a PDP that is terminating on December 31 (which is the case for some PDP enrollees in 2025, as there are 22% fewer PDPs available for 2026 than there were for 2025),¹ you qualify for a special enrollment period that continues through the last day of February.² And if you sign up for a replacement plan by December 31, your new plan will take effect January 1, meaning that you’ll have no gap in coverage.

But if your PDP is renewing for 2026 and you’re not eligible for a special enrollment period (addressed below), you’ll likely have to wait until next fall to switch to a different PDP that takes effect in 2027.

If you’ve realized that your PDP doesn’t adequately cover your medications, Medicare.gov has some tips for reducing your prescription costs, including Pharmaceutical Assistance Programs.

Could missing Medicare open enrollment result in a penalty?

Medicare open enrollment is an opportunity to sign up for Medicare Part D prescription drug coverage, so missing the enrollment window could result in a larger Part D late-enrollment penalty, since the penalty depends on the number of months you go without creditable drug coverage.

Since you generally won’t have an opportunity to sign up for Medicare Part D until the next open enrollment period, the number of months used to calculate your late-enrollment penalty will grow by 12 each year that you miss open enrollment. This makes it especially important not to miss the next Medicare open enrollment period.

Read our overview of the Medicare Part D late-enrollment penalty.

What makes you eligible for a special enrollment period for Medicare?

A variety of situations can trigger a special enrollment period for Medicare Advantage and/or PDPs for individuals — and in some cases, Medigap plans. They include life changes like moving out of your plan’s coverage area, losing other coverage, or an enrollment decision (including non-enrollment) caused by a federal employee’s error.

If you think you might be eligible for a special enrollment period, you can call 1-800-MEDICARE to discuss the situation with a Medicare representative.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written hundreds of opinions and educational pieces about the Affordable Care Act and Medicare for healthinsurance.org and medicareresources.org.

1. ”A Current Snapshot of the Medicare Part D Prescription Drug Benefit” KFF.org. Oct. 7, 2025
2. “CY2024 PDP Enrollment and Disenrollment Guidance” (Page 29) CMS.gov, Aug. 15, 2023

Fortunately, when you know what costs to expect, you can find ways to minimize them and protect yourself.

Eight ways to help minimize out-of-pocket costs

You cannot avoid all out-of-pocket costs when selecting a Medicare plan, but you can do your best to minimize them. Most importantly, you can plan and try to anticipate them so you can avoid surprise medical bills. Here’s what you can do:

1. Sign up on time

Enroll in Medicare on time to avoid late penalties, especially because you could get stuck paying some of those penalties for as long as you have Medicare coverage. It is important to not miss these deadlines.

Medicare Parts A and Part B:

• The Initial Enrollment Period (IEP) starts three months before and ends three months after the month you turn 65.¹² You can delay signing up for Part B, penalty-free, as long as you have a group health plan through your current employer or your spouse’s current employer. In that case, you can enroll in Part B without a penalty while you’re still covered by the employer’s plan, or within eight months of that coverage ending.¹³ Learn more about Medicare’s special enrollment periods. (Note that if your employer has fewer than 20 employees, they may require you to sign up for Medicare to stay on their employer plan. You’ll need to enroll in Part B as well as Part A, as Medicare will provide primary coverage and your employer’s plan will be secondary.)
• You can also qualify for Medicare based on a disability. Specifically, you can enroll in Medicare after 24 months of receiving Social Security Disability Insurance (SSDI) benefits.¹⁴ People who have Amyotrophic Lateral Sclerosis (ALS) are eligible as soon as they start SSDI and people with end-stage renal disease (ESRD) are eligible after they complete four months of dialysis at a clinic, right away if they receive dialysis at home, or when they stay in a hospital for a kidney transplant. Learn more about Medicare for those with ALS or ESRD.
• There’s no late enrollment period for Medicare Part A unless you’re in the approximately 1% of beneficiaries who have to pay a premium for Part A.¹⁵ That means you can sign up for Medicare Part A at any time – without a penalty – as long as you qualify for premium-free Part A (if you or your spouse worked 10 years in Medicare-taxed employment). But if you’re in the 1% of beneficiaries who have to pay a premium for Medicare Part A, you can enroll in it during your initial enrollment period, during a special enrollment period, or during the annual general enrollment period. In other words, the same enrollment limitations that apply to Medicare Part B for everyone.

Medicare Part D:

• The Initial Enrollment Period for Medicare Part D is the same as for Parts A and B. You’re allowed to delay enrolling in Part D and avoid a late penalty as long as you have creditable coverage (coverage as good as a standard Medicare Part D plan). In that case, you have 63 days to sign up for a Part D plan after your other creditable coverage ends.¹⁶ If you are not sure whether your current coverage qualifies as creditable, reach out to your health plan to find out.

2. Pick the right Medicare doctors

Choose doctors – whenever possible – who not only accept Medicare for payment but who also accept assignment. This means they signed a contract to charge no more than Medicare-approved rates for their services.¹⁷

This agreement also allows them to offer you certain preventive screening services – such as screening mammograms and colonoscopies – at no cost to you.¹⁸

The same cannot be said for doctors who do not accept assignment. Not only will you pay coinsurance for preventive screening services they order, but they can also charge up to 15% more than what Medicare recommends. This “excess charge” – also called the “limiting charge” – can sometimes be covered by a Medicare supplement plan (see #4 below), and some states impose limits on excess charges.¹⁹

If you are enrolled in a Medicare Advantage plan, you also want to be sure to pick a doctor in your plan’s network. Unless you get care in an emergency or you are not notified ahead of time that a provider at an in-network facility is not in your network, there is no guarantee your plan will cover an out-of-network provider. You could find yourself paying a higher rate or not being covered at all.

Enrollees who also have Medicaid should try to visit doctors who also accept Medicaid (and, if applicable, their Medicaid managed care plan). They work together to keep your costs down. Medicare will be the primary payer, which means it will pay first. Medicaid pays last, which means it can pay costs that aren’t paid by Medicare or any other insurance you might have.²⁰

3. Ask about your hospital orders

Not all hospital stays are billed the same – even when you stay overnight. Ask your doctor about your orders – inpatient or observation – when you stay in the hospital.

When you’re admitted as an inpatient, Part A coverage kicks in to pay for hospital care. When you are placed under observation, Part B pays.

• Part A: For the first 60 days of an inpatient hospital stay, you pay a flat rate for all hospital services. This Part A deductible is paid once per benefit period and is $1,736 in 2026.⁹ Note that physician services received while you’re in the hospital will generally be covered under Part B, which has a $283 deductible in 2026, and then you’ll pay 20% of the Medicare-approved cost.²¹
• Part B: How much you pay varies depending on how long you are under observation. In many cases, care you receive is bundled into one payment referred to as a comprehensive ambulatory payment classification (APC).²² You would pay 20% of that APC rate, after you’ve paid your Medicare Part B deductible. Those rates will vary based on the kind of care you received. Certain services and procedures, however, may add to those costs.

It can sometimes be hard to know if you would pay more out of pocket under Part A or Part B. In general, if your care involves multiple expensive procedures or tests (such as MRIs or CT scans, for example), it’s easy to see how the 20% coinsurance under Medicare Part B could add up to more than the Medicare Part A deductible. But this will depend entirely on the specific care that’s provided. No one service (administered in a hospital) billed under Part B can have out-of-pocket costs higher than the Part A deductible,²³ but the combination of several services can add up to more than the Part A deductible.

In some cases, an inpatient classification will end up having a lower out-of-pocket cost, while an observation classification will end up having a lower out-of-pocket cost in other cases. But it’s important to note that the decision is made by your medical providers, so it’s not something you can request one way or the other. (There are provisions for appeal in some cases.)²⁴

Hospital orders also affect whether or not Medicare will pay for your stay in a skilled nursing facility. To have coverage for the skilled nursing facility stay, you need to be an inpatient in the hospital for at least three days before transferring to the skilled nursing facility. Without those inpatient orders, you are responsible for all nursing facility costs out of pocket.²⁵

If you have Medicare Advantage, the out-of-pocket amounts will be set by your plan. You may need to obtain prior authorization for certain services, and your plan can impose deductibles, copays, and/or coinsurance for various services. This will differ from one plan to another, so make sure you understand the out-of-pocket details for your plan.²⁶

4. Consider Medicare supplement plans

Consider a Medicare supplement plan – also known as Medigap – to save on Original Medicare out-of-pocket costs you would otherwise have to pay yourself. Medigap is coverage that supplements Original Medicare, covering some or all of the out-of-pocket costs that a beneficiary would otherwise have to pay for services covered by Original Medicare. Depending on the plan you choose, a Medigap plan can help to cover your Part A deductible, Part A/B coinsurance, “excess charges” (see #2) and even emergency healthcare you receive in a foreign country.²⁷

That said, Medicare supplement plans add to your out-of-pocket costs, since they also require a monthly premium. You have to decide whether a Medigap plan could save you more money in the long run.

If you want a Medigap plan, be aware that in most states you only have one opportunity to enroll in a Medigap plan on a guaranteed-issue basis (meaning regardless of your medical history). This window lasts for six months after you’re at least 65 and enrolled in Medicare Part B.²⁸ After that, in most states, you’ll only have guaranteed issue access to Medigap coverage in very limited special enrollment period situations.

5. Look into Medicare Savings Programs

Medicare Savings Programs (MSPs) can help pay for Medicare Part A and Medicare Part B premiums, deductibles, copays, and coinsurance for enrollees with limited income and limited assets.²⁹

Learn how Medicare Savings Programs can help with your costs.

Likewise, check to see if you’re eligible for Extra Help if you are unable to afford your Part D prescription drug expenses.³⁰ These programs, which are based on your financial situation, can decrease your costs or eliminate some of them altogether. (Eligibility rules vary somewhat from state to state, as Extra Help is part of each state’s Medicaid program. Select your state on this map to learn more.)

Learn more about Medicare’s Extra Help.

6. Watch for billing errors

Check your Medicare bills for accuracy. Paying for services that were never provided or for other billing errors is wasteful. Do not hesitate to reach out to your doctor’s billing office if you have questions or concerns.

If you’re on Original Medicare, you’ll get a statement from Medicare every four months (if you had any services during the last four months) detailing the services you received.³¹ It’s important to pay attention to this statement and make sure you received all of the care that’s listed. If you have coverage under a Part D prescription drug plan, Medigap, or a Medicare Advantage plan, you’ll receive an explanation of benefits after you’ve received covered care. It’s important to also check these documents to make sure that you received the care that’s listed.

Medicare fraud and identity theft do sometimes happen. If you suspect your Medicare number is being misused or you suspect other fraudulent activity, you should reach out to 1-800-MEDICARE (1-800-633-4227) or TTY 1-877-486-2048 as soon as possible to report your concerns.³²

7. File an appeal

Medicare claims can be denied for a number of reasons. Unless you are on Original Medicare and signed an Advance Beneficiary Notice where you waive your right to an appeal, you should take the necessary steps to try and get your service(s) covered if you and your healthcare provider see them as medically necessary.³³ The specifics of the appeals process will depend on whether you have Original Medicare or a Medicare Advantage plan. Both are outlined here.

Nearly all Medicare Advantage plans require prior authorizations for certain services.³⁴

Interestingly, the Office of the Inspector General reported in 2022 that some Medicare Advantage plans were denying or delaying care for services that would otherwise be covered by Original Medicare.³⁵ As many as 13% of the coverage requests they reviewed were inappropriately denied. Hopefully, enrollees knew to file an appeal in those cases.³⁶

According to KFF, 50 million Medicare Advantage prior authorization requests were placed in 2023 with 3.2 million of them fully or partially denied. Enrollees only sought an appeal in 11.7% of those cases, but nearly 82% of the appeals resulted in the denial being partially or fully overturned fully or in part.³⁴ It goes to show that it is often well worth the time and effort to file an appeal.

Original Medicare rarely requires prior authorization. A new pilot program starts in 2026 in six states, requiring prior authorization for a limited number of services covered by Original Medicare. But the vast majority of care covered by Original Medicare does not require prior authorization.³⁷

However, if Original Medicare denies coverage for a service (even after you appeal the decision), you are responsible for Medicare’s rate for it unless the provider did not have you sign an Advance Beneficiary Notice of Non-Coverage (ABN) before the service was completed.³³ You can usually find the rate for Part B services online by visiting your Part B Medicare Administrative Contractor (MAC’s) website.

This amount is often much lower than a provider’s billed charges. Note that ABNs are only applicable to Original Medicare. And they are only used for services that are sometimes covered and sometimes not covered, depending on the circumstances. They are not used for services that are never covered by Original Medicare.³⁸

If you have a Medicare Advantage plan, the out-of-pocket costs for a denied claim will vary from plan to plan.³⁹ You’ll want to discuss these details with your Medicare Advantage plan and your medical provider before receiving care.

Learn how you can appeal a denied medical service or prescription.

8. Negotiate, Negotiate, Negotiate

Negotiate with your doctor, hospital, laboratory facility, etc., if your plan does not cover a specific service you need. There’s no guarantee they will agree, but they could potentially offer you lower rates, like they often do for people who do not otherwise have insurance.⁴⁰

Tanya Feke, M.D. is a licensed, board-certified family physician living in New Hampshire. As a practicing primary care physician in Connecticut and an urgent care physician in New Hampshire, she saw first-hand how Medicare impacted her patients. In recent years, her career path has shifted to consultant work with a focus on utilization management and medical necessity compliance.

Dr. Feke is an expert in the field, having Medicare experience on the frontlines with patients, hospital systems, and insurers. To educate the public about ongoing issues with the program, she authored “Medicare Essentials: A Physician Insider Reveals the Fine Print.” Her analysis of Medicare issues is frequently referenced by the media, and she is a contributor to multiple online publications.

1. “Health Costs Consume a Large Portion of Income for Millions of People with Medicare” KFF.org, Aug. 21, 2025
2. ”What Part A covers” Medicare.gov. Accessed Dec. 2, 2025
3. ”Home health services” Medicare.gov. Accessed Dec. 2, 2025
4. ”What Part B covers” Medicare.gov. Accessed Dec. 2, 2025
5. ”Mental health care (outpatient)” Medicare.gov. Accessed Dec. 2, 2025
6. ”Vaccines and immunizations” Medicare Rights Center. Mar. 31, 2025
7. ”Understanding Medicare Advantage Plans” Medicare.gov. Accessed Dec. 2, 2025
8. “August 2025 Medicare Monthly Enrollment” CMS.gov. Accessed Dec. 2, 2025
9. ”Costs” Medicare.gov. Accessed Dec. 2, 2025
10. ”Final Contract Year (CY) 2026 Standards for Part C Benefits, Bid Review and Evaluation” Centers for Medicare & Medicaid Services. Apr. 16, 2025
11. ”Medicare Advantage in 2025: Premiums, Out-of-Pocket Limits, Supplemental Benefits, and Prior Authorization” KFF.org. July 28, 2025
12. ”When does Medicare coverage start?” Medicare.gov. Accessed Dec. 2, 2025
13. ”How to Apply for Medicare Part B (Medical Insurance) During Your Special Enrollment Period” Social Security Administration. Accessed Dec. 2, 2025
14. ”Original Medicare (Part A and B) Eligibility and Enrollment” Centers for Medicare & Medicaid Services. Accessed Dec. 2, 2025
15. ”2026 Medicare Parts A & B Premiums and Deductibles” Centers for Medicare & Medicaid Services. Nov. 14, 2025
16. “Creditable Coverage and Late Enrollment Penalty” CMS.gov. Accessed Dec. 2, 2025
17. ”Does your provider accept Medicare as full payment?” Medicare.gov. Accessed Dec. 2, 2025
18. “Your Guide to Medicare Preventive Services” Medicare.gov. Accessed Dec. 2, 2025
19. “Limiting Charge” Medicare Interactive Glossary. Accessed Dec. 2, 2025
20. “Medicaid” Medicare.gov. Accessed Dec. 2, 2025
21. ”Inpatient Hospital Care” Medicare.gov. Accessed Dec. 2, 2025
22. ”APC (Ambulatory Payment Classifications) FAQ” American College of Emergency Physicians. Accessed Dec. 2, 2025
23. ”Inpatient or outpatient hospital status affects your costs” Medicare.gov. Accessed Dec. 2, 2025
24. ”Medicare Patients Placed Under “Observation Status” Win Right to Appeal, Federal Court Orders” Justice in Aging. Mar. 24, 2020
25. ”Skilled nursing facility care” Medicare.gov. Accessed Dec. 2, 2025
26. “Understanding Medicare Advantage Plans” Medicare.gov. Accessed Dec. 2, 2025
27. ”What’s Medicare Supplement Insurance (Medigap)?” Medicare.gov. Accessed Dec. 2, 2025
28. “Get Ready to Buy; Your Medigap Open Enrollment Period” Medicare.gov. Accessed Dec. 2, 2025
29. ”Medicare Savings Programs” Medicare.gov. Accessed Dec. 2, 2025
30. ”Help with drug costs” Medicare.gov. Accessed Dec. 2, 2025
31. ”Medicare Summary Notice (MSN)” Medicare.gov. Accessed Dec. 2, 2025
32. ”Reporting Medicare fraud & abuse” Medicare.gov. Accessed Dec. 2, 2025
33. ”Filing an appeal” Medicare.gov. Accessed Dec. 2, 2025
34. ”Medicare Advantage Insurers Made Nearly 50 Million Prior Authorization Determinations in 2023” KFF.org Jan. 28, 2025
35. “Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care” HHS.gov April 27, 2022
36. “Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care” HHS.gov. April 27, 2022
37. ”CMS Launches New Model to Target Wasteful, Inappropriate Services in Original Medicare” Centers for Medicare & Medicaid Services. June 27, 2025
38. ”Medicare Non-covered Services” AAFP.org. Accessed Dec. 2, 2025
39. ”How to Collect for Non-Covered Services Under MA Plans” Healthcare Training Leader. Nov. 7, 2022
40. “Negotiating Medical Costs” Patient Advocate Foundation. Accessed Dec. 2, 2025

In this article

• Inflation Reduction Act provisions that took effect in 2023
• Inflation Reduction Act provisions that took effect in 2024
• Inflation Reduction Act provisions that took effect in 2025
• Drug negotiation provisions phased in starting in 2026

The Inflation Reduction Act (IRA), signed into law in 2022, is reshaping how Medicare covers prescription drugs. Beginning in 2023, a series of changes began to be phased in under the IRA, designed to lower out-of-pocket costs, expand access to vaccines, and rein in drug price increases.

These reforms – which will continue to roll out through 2029 – mean that millions of Medicare beneficiaries are seeing tangible improvements in how much they pay at the pharmacy and how their coverage works.

Let’s take a look at how the IRA has changed coverage for Medicare beneficiaries:

Inflation Reduction Act provisions that took effect in 2023

The first improvements took effect in January 2023. At that point (and going forward):

Copays for all insulin products are capped at $35/month for all Part D plans.

Under pre-IRA rules, some Medicare beneficiaries already had this benefit for some insulin products, thanks to the Senior Savings Model (SSM), which required participating Medicare Part D plans to offer select insulin products at $35/month or less. This opt-in program had been in use since 2021, and roughly 17 million Medicare beneficiaries were enrolled in Part D plans that participated in the SSM.

Under the IRA, the $35/month copay cap for insulin was extended to include all Part D plans (including Part D coverage that’s integrated with most Medicare Advantage plans) and all insulin products, including those dispensed via insulin pumps.. Note that GLP-1 receptor agonists are not insulin and thus are not subject to this rule. (Here’s more about Medicare Part D coverage of GLP-1 receptor agonists.) Note also that Part D plans still have formularies that determine which insulin products they cover; different plans cover different insulins.

Recommended vaccines are free for Medicare Part D enrollees

Under pre-IRA rules, vaccines covered under Medicare Part B (COVID, flu, pneumonia, hepatitis B) were already free.¹ But vaccines covered by Part D – including Tdap (tetanus, diphtheria, pertussis) and shingles vaccines – had cost-sharing that varied from one plan to another. This meant Medicare beneficiaries could be paying hundreds of dollars in out-of-pocket costs in order to get the vaccines that the CDC’s Advisory Committee on Immunization Practices (ACIP) recommended for them.

The IRA’s new rules brought Medicare Part D in line with individual/family and employer-sponsored health plans. With the exception of grandfathered plans, these policies have been required to cover all ACIP-recommended vaccines without any cost-sharing for well over a decade, thanks to the Affordable Care Act (ACA). Since 2023, thanks to the IRA, people with Medicare Part D have had the same benefit.

Drug manufacturers pay rebates when price increases exceed the rate of inflation

Starting in 2023, drug manufacturers have had to pay rebates to Medicare if the price of their prescription drugs increases faster than the rate of inflation (CPI-U).² This applies to all but the least expensive Part D drugs, as well as single-source drugs and biologicals that are covered under Part B. (Most drugs are covered under Part D, but some are covered under Part B instead).

Since April 2023, Medicare Part B enrollees could have lower out-of-pocket costs (than they would otherwise have had) for certain Part B-covered drugs if the drug price increases have outpaced inflation. Coinsurance under Medicare Part B is 20%, but beneficiaries who use these medications pay a coinsurance rate that’s less than 20% (the specific percentage varies from one drug to another).

Note that many Medicare beneficiaries have supplemental coverage, from Medigap, Medicaid, or an employer-sponsored plan, that will pay their Part B out-of-pocket costs.³ So the out-of-pocket impact for enrollees depends on whether they pay their own Part B coinsurance.

A similar rebate system already operated in the Medicaid program, and plays a significant role in keeping drugs costs lower for Medicaid.

If a Medicare Part B enrollee receives a medication that has a reduced coinsurance, their bill will simply reflect the lower out-of-pocket costs. But for those who are curious about which drugs these are, CMS has been publishing the details each quarter. For 2023, 2024, and the first quarter of 2025, CMS published quarterly fact sheets that listed the Part B drugs subject to a rebate, and indicated their reduced coinsurance amount (ie, something less than 20%).⁴ Starting with the second quarter of 2025, the coinsurance amounts are instead simply included in CMS’s quarterly average sales price (ASP) Pricing Files.⁵

Inflation Reduction Act provisions that took effect in 2024

These additional improvements took effect starting in 2024:

The 5% coinsurance in the Part D catastrophic coverage level was eliminated.

Prior to 2024, Medicare Part D enrollees had to pay up to 5% of the cost of their covered drugs once they reached the catastrophic coverage level. But starting in 2024, due to the IRA, Part D enrollees no longer to pay any out-of-pocket costs for covered medications after they reached the catastrophic coverage level.⁶ For Part D drug spending, this effectively resulted in an out-of-pocket cap of about $3,250 in 2024⁷(as noted below, this was further reduced starting in 2025).

The cost-structure for Medicare Part D was fairly complicated before the IRA’s reforms. The ACA “closed” the Part D donut hole, but enrollees’ costs still changed when they hit the initial spending threshold where the donut hole used to begin (as described below, the IRA fully eliminated the donut hole as of 2025). And although costs were (and still are) split between the enrollee, the plan, and the manufacturer (with different splits depending on how much the person has spent that year), actual out-of-pocket costs were much higher before 2024 for some enrollees  whose costs pushed them into the catastrophic coverage level, where they paid 5% coinsurance without any cap on how much they spent.

Under the IRA, starting in 2024, enrollees no longer had any out-of-pocket costs for covered drugs once they reached the catastrophic coverage level. The amount paid by Part D plans increased to cover the amount that was previously paid by enrollees.⁸

The full Low-Income Subsidy (Extra Help) became available to more beneficiaries.

The Low-Income Subsidy, also known as Extra Help is a program that helps pay Part D coverage and prescription out-of-pocket costs  for enrollees with limited income and assets.⁹

Prior to 2024, Extra Help was available either partially or in full, depending on income and assets: Full Extra Help was available to beneficiaries with income up to 135% of the federal poverty level , and partial Extra Help was available to beneficiaries with income up to 150% of the poverty level, with higher asset/resource limits for partial Extra Help eligibility.

Under the IRA, starting in 2024, full Extra Help eligibility was extended to enrollees with income up to 150% of the federal poverty level (FPL), as long as their assets didn’t exceed the asset limits.¹⁰ (As of 2025, 150% of FPL in the continental U.S. is $23,475 for a single individual and $31,725 for a married couple.¹¹ The asset limits for Extra Help in 2025 are $17,600 for a single individual and $35,130 for a married couple.¹² These numbers are adjusted annually.)

Full Extra Help means these beneficiaries will pay no premiums for the Part D benchmark plan, have no Part D deductible, and will only pay copays at the pharmacy of $5.10 for generic drugs and $12.65 for brand-name drugs in 2026.¹³

Annual Part D premium increases are limited.

Under the IRA, from 2024 through 2030, the national base beneficiary premium for Part D coverage can’t increase by more than 6% per year.

For perspective, the national base beneficiary premium is $36.78/month in 2025,¹⁴ and will increase to $38.99/month in 2026.¹⁵

The national base beneficiary premium is essentially an average premium amount for standard Part D coverage. The amount of the Part D late enrollment penalty is based on the cost of the base beneficiary premium, which is why the penalty amount changes each year.¹⁶ But when it comes to the premiums that people pay for Part D coverage, there is wide variation from one plan to another. In 2025, premiums for national Part D plans vary from as little as $3/month to more than $100/month.¹⁷

The IRA’s limit on base beneficiary premium increases helps to prevent insurers from pushing the cost of the new coverage requirements onto beneficiaries in the form of higher premiums.¹⁸ But the IRA does not mean that every plan’s premium increases are capped at 6% per year. This brief from CMS explains how the base beneficiary premium is used to calculate plan-specific premiums for each plan’s basic benefit. For perspective,  CMS announced in 2023 that the base beneficiary premium for 2024 would be $34.70. Without the 6% cap, if the calculation had been based just on bids submitted by the carriers, it would have been $39.35.¹⁹

Inflation Reduction Act provisions that took effect in 2025

One of the most highly anticipated IRA improvements took effect in 2025, capping out-of-pocket costs under Medicare Part D at $2,000. As noted above, the elimination of the 5% coinsurance in the catastrophic level of coverage effectively implemented a Part D out-of-pocket cap of about $3,250 in 2024. But in 2025, out-of-pocket costs for drugs covered under Part D are capped at $2,000 for all enrollees. This includes the deductible and any copays or coinsurance that they pay.²⁰ The legislation clarified that the $2,000 cap could increase in subsequent years if Medicare’s per-enrollee drug spending increases. For 2026, the Part D out-of-pocket cap is $2,100.²¹

As of 2025, the Part D coverage gap (donut hole) phase was eliminated. Standard Part D coverage now has just three phases: the deductible phase, the initial coverage phase, and the catastrophic phase (after the out-of-pocket cap has been reached and the person no longer has any costs for covered drugs).¹⁴

Since the IRA is shifting more drug costs onto Part D plans, there were concerns that premiums might increase significantly or plans might exit the market for 2025. So CMS introduced a temporary premium stabilization program for Medicare Part D.²² For 2025, the program gave participating insurers $15/month for each enrollee, to offset what would otherwise have been higher premiums for enrollees, and capped premium increases for participating Part D plans at no more than $35/month for 2025 coverage.²³

For 2026, CMS opted to continue the temporary Part D premium stabilization program, but with reduced assistance to the insurers. Instead of $15/month for each enrollee, participating insurers will receive $10/month in federal subsidies in 2026. And premium increases for participating insurers are capped at $50/month for 2026, instead of the $35/month limit that applied for 2025 coverage.¹⁵

Starting in 2025, Part D enrollees also have the option to spread their costs out over the year, paid monthly. This makes it easier for beneficiaries on a fixed income to budget for their prescription costs.²⁴

Prior to 2025, beneficiaries with high-cost drugs could hit the catastrophic coverage level early in the year, potentially spending thousands of dollars in a short period of time. Under the new rules, even if a person is going to hit the $2,000 cap ($2,100 in 2026),²⁵ they have the option to split that into monthly payments of about $167 (about $175 in 2026), instead of paying the whole amount in the first few months of each year. This is detailed in Section 11202 of the IRA.

Drug negotiation provisions phased in starting in 2026

Starting in 2026, ten high-cost drugs will have lower prices due to Medicare negotiating with the drug manufacturers. The ten drugs with negotiated prices in 2026 are some of the most expensive drugs, and relatively few drugs account for the majority of Medicare’s drug spending. The first year of negotiated rates, applicable to 10 drugs, will be 2026. But the process began in 2023:²⁶

• In 2023, HHS published a list of 10 Part D drugs that would be subject to negotiation²⁷ (selected from among the 50 qualifying drugs with the highest spending; various rules apply here, including the fact that the drugs must have been on the market for several years and not have generic alternatives).
• HHS negotiated with the drug manufacturers, following protocol outlined in the IRA. In August 2024, HHS published the “maximum fair price” for those 10 drugs, which will take effect in 2026.²⁸
• The process will continue for each of the next few years, with additional drugs added to the negotiation process each year through 2029. Another 15 drugs were added for 2027,²⁹ 15 more will be added for 2028, and 20 more will be added for 2029. So by that point, there will be 60 drugs subject to negotiation, all of which will be among the most expensive drugs that don’t have generic alternatives. In the latter two years, the newly added drugs will potentially be a mix of Part D and Part B drugs, whereas the negotiated rates in 2026 and 2027 will all apply to Part D drugs.³⁰
• The “One Big Beautiful Bill,” enacted in July 2025, included some provisions that expand the number of drugs that aren’t eligible for price negotiations.³¹³²
• Drug manufacturers that do not comply with the negotiation process will be subject to financial penalties. Alternatively, they can choose to no longer have their drugs covered under the Medicare and Medicaid programs.

The IRA’s Medicare drug pricing provisions will benefit millions of Medicare beneficiaries. The ACA began the process of improving Part D benefit, by gradually closing the donut hole. But the IRA goes much further, and implements some very tangible benefits, particularly for those who need high-cost medications.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written hundreds of opinions and educational pieces about the Affordable Care Act and Medicare for healthinsurance.org and medicareresources.org.

1. “How to Pay for Vaccines” CDC.gov. July 10, 2024
2. “Require Drug Manufacturers to Pay Rebates for Price Increases Above Inflation for Drugs Used by People with Medicare” KFF.org. Jan. 24, 2023
3. “A Snapshot of Sources of Coverage Among Medicare Beneficiaries” KFF.org. Sep. 23, 2024
4. “Medicare Inflation Rebate Program” Centers for Medicare & Medicaid Services. Accessed Sep. 10, 2025
5. “ASP Pricing Files” Centers for Medicare & Medicaid Services. Accessed Sep. 10, 2025
6. “Changes to Medicare Part D in 2024 and 2025 Under the Inflation Reduction Act and How Enrollees Will Benefit” KFF.org. Apr. 20, 2023
7. “As illustrated on Slide 11 in this KFF slide deck, that amount included out-of-pocket spending in the deductible phase, initial coverage phase, and coverage gap/donut hole phase” KFF.org. Aug. 11, 2022
8. “What to Know About Medicare Part D Premiums” (Figure 1) KFF.org. Aug. 1, 2024
9. “Help with drug costs” Medicare.gov. Accessed Oct. 8, 2025
10. “HI 03001.005 Medicare Part D Extra Help (Low-Income Subsidy or LIS)” Social Security Administration. Accessed Sep. 10, 2025
11. “2025 Poverty Guidelines” U.S. Department of Health & Human Services. Accessed Aug. 10, 2025
12. “Help with drug costs” Medicare.gov. Accessed Sep. 10, 2025
13. “Help with drug costs” Medicare.gov. Accessed Nov. 17, 2025
14. “CMS Releases 2025 Medicare Part D Bid Information and Announces Premium Stabilization Demonstration” Centers for Medicare & Medicaid Services. July 29, 2024
15. “2026 Medicare Part D Bid Information and Part D Premium Stabilization Demonstration Parameters” Centers for Medicare & Medicaid Services. July 28, 2025
16. “The Part D Late Enrollment Penalty” Centers for Medicare & Medicaid Services. Accessed Oct. 8, 2025
17. “Key Facts About Medicare Part D Enrollment, Premiums, and Cost Sharing in 2025” KFF.org. July 16, 2025
18. “Medicare Part D Premium Stabilization Demonstration” Congress.gov. Jan. 30, 2025
19. “Annual Release of Part D National Average Monthly Bid Amount and Other Part C & D Bid Information” Centers for Medicare & Medicaid Services. July 31, 2023
20. “Understanding the Health Care Provisions in the Inflation Reduction Act” KFF.org. Aug. 11, 2022
21. “Draft CY 2026 Part D Redesign Program Instructions Fact Sheet” Centers for Medicare & Medicaid Services. Jan. 10, 2025
22. “CMS Releases Preliminary 2025 Medicare Part D Bid Information and Announces Premium Stabilization Demonstration” CMS Newsroom. July 29, 2024
23. “CMS Releases 2025 Medicare Part D Bid Information and Announces Premium Stabilization Demonstration — National Average Monthly Bid Amount & Government Subsidy” Centers for Medicare & Medicaid Services. July 29, 2024
24. “Medicare Prescription Payment Plan” Centers for Medicare & Medicaid Services. Accessed Oct. 8, 2025
25. ”Final CY 2026 Part D Redesign Program Instructions” Centers for Medicare & Medicaid Services. Apr. 7, 2025
26. “Understanding the Health Care Provisions in the Inflation Reduction Act” KFF.org. Aug. 11, 2022
27. “Medicare Drug Price Negotiation Program: Selected Drugs for Initial Price Applicability Year 2026” Centers for Medicare & Medicaid Services. Aug. 2023
28. “Medicare Drug Price Negotiation Program: Negotiated Prices for Initial Price Applicability Year 2026” Centers for Medicare & Medicaid Services. Aug. 15, 2024
29. “HHS Announces 15 Additional Drugs Selected for Medicare Drug Price Negotiations in Continued Effort to Lower Prescription Drug Costs for Seniors” Centers for Medicare & Medicaid Services. Jan. 17, 2025
30. “Understanding The Democrats’ Drug Pricing Package” Health Affairs. Aug. 10, 2022
31. “Congress Expands Orphan Drug Exemptions From Medicare Price Negotiations” Jones Day. July 28, 2025.
32. “OBBBA and Medicare Negotiation Eligibility: Considerations for Manufacturers” Avalere Health. July 23, 2025

In this article

• Medicare surcharges called IRMAAs apply to higher earners.
• Make qualified charitable distributions
• Make Roth conversions
• Max out traditional IRA or 401(k) contributions
• Delay collection of Social Security benefits

If you’re a Medicare enrollee with a high income, you may face an income-related surcharge on your Medicare Part B and Part D premiums. But some Medicare enrollees are able to avoid having to pay this surcharge through strategies that reduce their household income.

Medicare surcharges called IRMAAs apply to higher earners

Medicare enrollees typically don’t have to pay a premium for Medicare Part A, which covers hospital care. But there are premiums associated with Medicare Part B – which covers outpatient care – as well as Medicare Part D prescription drug plans. The standard monthly Part B premium changes annually and is currently $185.¹ The amount of Medicare Part D premiums are plan-specific.

But depending on your income, you may be assessed a surcharge on your Part B and Part D premiums known as an income-related monthly adjustment amount, or IRMAA.² IRMAAs are calculated based on a form of your modified adjusted gross income (MAGI)³ from two years prior. Whether you’ll be impacted by an IRMAA in 2025, for example, hinges on your income from 2023. (If your income or circumstances have changed, however, you can file an appeal with the Social Security Administration and ask them to reduce or remove your IRMAA surcharge.)

In 2025, IRMAAs are not applicable if you’re an individual tax-filer with a MAGI of $106,000 or less, or a joint filer with a MAGI of $212,000 or less.⁴ Since 2020, these thresholds have been indexed annually for inflation, and have increased each year.⁵

Although IRMAAs only impact approximately 8% of  enrollees in each of Medicare Part B and Part D,⁶ not having to pay them – even temporarily – could result in significant reductions in the amount of your Part B and Part D premiums. You may want to work with a financial advisor or tax planner to discuss whether any of these strategies could reduce your IRMAA-specific MAGI so that you don’t have to pay an IRMAA surcharge.

1. Make qualified charitable distributions

Charitable donations on their own do not reduce your MAGI. But making what are known as qualified charitable distributions (QCDs) could.

If you have a traditional IRA, you’re required to take required minimum distributions (RMDs) beginning at age 73 if you were born between 1951 and 1959, or starting at age 75 if you were born in 1960 or later. RMDs count toward your MAGI. But a QCD, which has you making a direct donation from your IRA to a registered charity, does not count as taxable income and can therefore reduce your MAGI.⁷, making an IRMAA less likely.

2. Make Roth conversions

Converting a traditional IRA or 401(k) to a Roth account prior to retirement could help you avoid IRMAAs by making your retirement plan withdrawals after retirement tax-free. But Roth conversions create a tax liability the year you make them.⁸ So be  aware that if you convert funds to a Roth IRA or Roth 401(k) too close to when you’re eligible for Medicare, you could actually raise your likelihood of facing an IRMAA two years later due to the increase in your taxable income in the year you made the conversion. Work with a tax professional to carefully time your conversions.⁹,¹⁰

3. Max out traditional IRA or 401(k) contributions

Medicare eligibility generally begins at age 65, and you’re allowed to sign up even if you’re still working and have access to a group health plan. But if you’re still earning an income, it means you may be eligible to contribute to a traditional IRA or 401(k).

If so, maxing out those contributions does the job of reducing your taxable income.¹¹ That, in turn, lowers your MAGI, which could mean avoiding having to pay an IRMAA surcharge two years down the road.

4. Delay collection of Social Security benefits

Social Security eligibility begins at 62, and many seniors start collecting benefits before they enroll in Medicare. If you delay your Social Security claim, not only can you lock in a larger monthly benefit for life, but you could avoid having to pay an IRMAA surcharge, at least for a period of time.¹²

If you’re not collecting Social Security at the time of your Medicare enrollment or in the years leading up to it, that reduces your likelihood of having to pay a Part B or D surcharge by virtue of lowering your income.

On the flip side, though, once you do claim Social Security, you’ll have a larger monthly benefit for a delayed filing. That increased income could put you at risk of IRMAAs down the line, so this may only be a temporary solution. Note that delayed retirement credits for Social Security stop accruing at age 70, so the strategy of postponing your filing will only work for so long.¹²

This article is intended for educational purposes only and is not tax advice. For guidance on your personal situation, please contact a tax professional or financial advisor.

Maurie Backman has been writing professionally for well over a decade, and her coverage area runs the gamut from healthcare to personal finance to career advice. Much of her writing these days revolves around retirement and its various components and challenges, including healthcare, Medicare, Social Security, and money management.

1. “Costs” Medicare.gov. Accessed Mar. 25, 2025
2. “Premiums: Rules for Higher-Income Beneficiaries” SSA.gov. Accessed Mar. 27, 2025
3. “The Use of Modified Adjusted Gross Income (MAGI) in Federal Health Programs” (Table 1) Congressional Research Service. Dec. 6, 2018
4. “Costs – Who pays a higher Part B premium because of income?” Medicare.gov. Accessed Mar. 25, 2025
5. “Historical Medicare IRMAA Brackets 2007 – 2023” IRMAA Certified Planner. Jan. 16, 2025
6. “2025 Medicare Parts A & B Premiums and Deductibles” CMS.gov. Nov. 8, 2024
7. “Qualified charitable distributions allow eligible IRA owners up to $100,000 in tax-free gifts to charity” IRS.gov. Nov. 16, 2023
8. “Why consider a Roth conversion now?” Fidelity. Accessed Mar. 25, 2025
9. “Retirement plans FAQs regarding IRAs” IRS.gov. Accessed Mar. 21, 2025
10. “How a Roth Conversion Can Spare You From Medicare’s IRMAA and Taxes” Kiplinger.com. Aug. 8, 2024
11. “Benefits of setting up a retirement plan” IRS.gov. Accessed Mar. 21, 2025
12. “Delayed Retirement Credits” SSA.gov. Accessed Mar. 27, 2025

After the government declared COVID-19 a national public health emergency, telehealth took off. The number of telehealth visits increased by more than 4,300% in March 2020 when compared to 2019.¹ A survey by the RAND Corporation found that 2052 out of 2622 (78%) people with commercial insurance – including Medicare Advantage – used telehealth between March and May 2020.² Commercial insurance refers to health plans that are run by private insurance companies, not by the state or federal government.

Former CMS director Seema Verma reported, in an article for Health Affairs, that more than 9 million Medicare beneficiaries used telehealth services during that time with a third of them simply doing so by phone.³

Is telehealth here to stay?

Defining telehealth

Tele- is derived from Greek, meaning “at a distance”.⁴ Think about how long we have used tele-technology. The telephone was invented in 1876. This was followed by the first radio broadcast in 1900 and the first television broadcast in 1927.

Telehealth is defined as healthcare “at a distance.”⁵ Medicare traditionally will cover care by certain healthcare providers if those services are given by two-way communication that uses both audio and video technology. You also had to be in certain locations, such as a doctor’s office or a hospital in a rural area. If you needed dialysis, regardless of where you were located, there was also a Medicare option for telehealth coverage. ⁶

Passage of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) in March 2020 changed the requirements for telehealth coverage, at least during the public health emergency, which ended on May 11, 2023. CARES increased Medicare coverage for more types of telehealth services regardless of where you were located in the country. Many of these services would continue through December 31, 2024 (subsequently extended to March 31, 2025 by legislation that was enacted in December 2024⁷).

During this time, it was no longer necessary to use technology that used both audio and visual for all telehealth services. Healthcare providers could deliver some types of care by audio-only telehealth too.

Limitations of video conferencing

The video requirement for Medicare coverage for telehealth appears to be the rate-limiting step. Not all Medicare beneficiaries have access to video conferencing technology and many may have physical limitations that decrease their ability to use it effectively, even when they do.

Take broadband connectivity. A high-speed, high-quality internet connection is a practical necessity for effective teleconferencing. Approximately 15% of Medicare beneficiaries live in rural communities.⁸ According to the Federal Communications Commission (FCC), approximately one in four people living in these communities do not have access to a broadband internet connection.⁹ Even when broadband services are available in rural communities, millions of Americans do not sign up for service whether for cost or other reasons.¹⁰

Chronic medical conditions and disabilities can also take their toll on telehealth usage. According to the most recent National Health Survey,  13.1 million adults 65 and over have vision loss.¹¹

When you consider that 25.7 million American adults report severe arthritis pain that affects their day to day function,¹² it’s possible dexterity issues could also come into play when it comes to using video conferencing equipment.

Easy access with audio-only services

It turns out the technology we needed all along was right in front of us. Telephones are easy to use and most people have access to one. Data from the National Health Statistics shows that more than 98.7% of Americans have access to a phone. ¹³

People who were unable to utilize video conferencing services, regardless of the reason, were able to access care with audio-only services if they needed to. The proof is in the pudding, as they say, with 3 million Medicare beneficiaries turning to their phones for telehealth visits in the first three months of the pandemic. This was a time when they did not have an option to go to the doctor’s office. It is possible they would have otherwise gone without needed care during this time.³

Physician shortages are another factor to consider. Rural counties account for the majority of designated health professional shortage areas in the country.¹⁴ People may have to travel long distances to see a provider, if they can access one at all. As noted previously, individuals in these areas may have more limited access to teleconferencing because broadband access is less available. Limiting telehealth to audio-video conferencing, instead of just audio-only, can unfairly deprive care to people who are already at a disadvantage.

Legislative changes could be on the way

The pandemic showed us that audio-only telehealth can be beneficial for Medicare beneficiaries, especially for those living in rural areas. The question is whether audio-only services offered during the pandemic will continue to be offered after Dec. 31, 2024, when they are currently set to expire.

As it currently stands, audio-only telehealth is available to Medicare beneficiaries for a limited number of conditions.¹⁵ This includes services for behavioral and mental health, chronic kidney disease, diabetes, in-hospital care, medical nutrition, and speech therapy. After December 31, 2024, permanent audio-only telehealth coverage will continue for many mental health services.

A number of U.S. Representatives have sought to extend coverage for audio-only telehealth for the long haul. The Permanency for Audio-Only Telehealth Act, Preserving Telehealth, Hospital, and Ambulances Act, and Telehealth Modernization Act of 2024 are all proposals made to extend telehealth options for Medicare beneficiaries and lift pre-pandemic restrictions.

Previously, beneficiaries on Original Medicare had to be at a community mental health center, critical access hospital, doctor’s office, federally qualified health center, hospital, hospital- or critical access hospital-based dialysis facility, rural health clinic, or skilled nursing facility for their visit to be covered. They could not be at home. The one exception was people who required routine check-ups for home dialysis. The catch was that they had to have already received three months of in-person visits before telehealth visits would be covered.

Without Congressional action, these rules will return in 2025, preventing Original Medicare beneficiaries from accessing telehealth from their homes for most services. And in-clinic telehealth care for beneficiaries in non-rural areas will be limited to a fairly short list of services.¹⁶

Medicare Advantage plans were allowed to expand their telehealth access in 2020, before the pandemic even began.¹⁷ The plans do not necessarily restrict access to telehealth to fixed locations like Original Medicare. In fact, telehealth benefits can now be included as part of a Medicare Advantage plan’s basic benefits package.

The bottom line

According to a survey from Statistica, approximately one in three of people in the U.S. prefer a telehealth visit to an in-office visit to help with their mental health and chronic conditions. Nearly half prefer telehealth for management of minor illnesses, and more than two thirds prefer it to help them arrange for prescription refills.¹⁸ “With the benefits of telehealth clearly highlighted during the pandemic, continued audio-only services may provide needed access to care for Medicare beneficiaries, at least for certain types of medical conditions.

Telehealth allows you to bypass travel to the office (saving time and gas) and receive care from the comfort of your own home, keeping you safe while also being cost-effective. If telehealth is covered by Original Medicare, you will be responsible to pay the usual 20% Part B coinsurance for your visit. If you have a Medicare Advantage plan, costs will depend on your plan.

While it is unclear what legislation will be passed in the future, one thing holds true: Telehealth services have changed how many people use healthcare. If you are someone who needs help, do not hesitate to reach out to your healthcare provider for a telehealth visit, if they offer them. If you are someone who could benefit from regular tele-healthcare, you may want to look closely at Medicare Advantage plans in your area.

Tanya Feke, M.D. is a licensed, board-certified family physician living in New Hampshire. As a practicing primary care physician in Connecticut and an urgent care physician in New Hampshire, she saw first-hand how Medicare impacted her patients. In recent years, her career path has shifted to consultant work with a focus on utilization management and medical necessity compliance.

Dr. Feke is an expert in the field, having Medicare experience on the frontlines with patients, hospital systems, and insurers. To educate the public about ongoing issues with the program, she authored “Medicare Essentials: A Physician Insider Reveals the Fine Print.” Her analysis of Medicare issues is frequently referenced by the media, and she is a contributor to multiple online publications.

1. “Top Five Procedure Codes by Utilization, 2019 vs. 2020” FAIRHealth. March 2020
2. “The Transition to Telehealth during the First Months of the COVID-19 Pandemic: Evidence from a National Sample of Patients” Journal of General Internal Medicine. Jan. 6, 2021
3. “Early Impact Of CMS Expansion Of Medicare Telehealth During COVID-19” Health Affairs. July 15, 2020
4. “Tele-” Merriam-Webster Dictionary. Accessed Dec. 10, 2024
5. “Telehealth” National Institutes of Biomedical Imaging and Bioengineering
6. Telehealth. CMS Medicare Learning Network.
7. ”US HR10545 — Further Continuing Appropriations Act, 2025 Health Extensions and Other Matters Act, 2025 Disaster Relief Supplemental Appropriations Act, 2025” BillTrack50. Enacted Dec. 21, 2024
8. “Medicare Advantage Enrollment, Plan Availability and Premiums in Rural Areas” KFF.org. Sep. 7, 2023
9. “Broadband | USDA” USDA.gov. Accessed Dec. 10, 2024
10. “Switched Off: Why Are One in Five U.S. Households Not Online?” NTIA.gov. Accessed Dec. 10,2024
11. “Facts and Figures on Adults with Vision Loss from the National Health Interview Survey (NHIS)” American Foundation for the Blind. February 2024
12. “Arthritis” CDC.gov. Accessed Dec. 10, 2024
13. “Data Reveals Landline Phone Decline Statistics” chamberofcommerce.org. Accessed Dec. 10, 2024
14. “HPSA Find” HRSA.gov. Accessed Dec. 10, 2024
15. “List of Telehealth Services” CMS.gov. Accessed Dec. 10, 2024
16. “Telehealth Update: DEA/HHS Temporary Rule, Medicare Coverage of Telehealth Services, and What to Watch For in 2025” Mintz. Dec. 4, 2024
17. “CMS finalizes policies to bring innovative telehealth benefit to Medicare Advantage” CMS.gov. April 5, 2019
18. “Distribution of preference between telemedicine and in-person care in the U.S. in 2023, by type of care needed” Statistica

But data breaches aren’t always that widespread – and they can be the result of a simple error rather than a malicious hack/ransomware incident. Regardless of the cause, it’s disconcerting to find out that your personal information has been impacted. Let’s take a look at what you need to know about Medicare data breaches.

How do I know if my personal information was affected by a data breach?

If your personally identifiable information (PII) and/or protected health information (PHI) is impacted by a data breach – either directly or via a third-party vendor – you will receive a letter through the U.S. Postal Service from the Centers for Medicare & Medicaid Services (CMS).²CMS will not call, email, or text you about a data breach or any action required on your part.

The letter will explain what happened, the specific PII and/or PHI that might have been compromised, what is being done to address the issue, and what steps, if any, you can or should take. You can read recent examples of these letters here and here.

If you’ve moved or there’s an error with your address, your notification letter may not arrive. If you didn’t receive a letter but want to put your mind at ease, you can call 1-800- MEDICARE (1-800-633-4227) to ask directly whether your Medicare account has been involved in any data breaches.

If you receive a phone call, text, or email from someone saying they’re with Medicare and that you need a new card – or need to do anything related to getting a new card – this is likely a scam, and it resurfaces regularly.

Don’t provide any information to the caller, and don’t respond to a text or email. If possible, report the details to your state’s Senior Medicare Patrol.

What should I do if I suspect my Medicare information was leaked?

If you receive a Medicare data breach notification from CMS, you’ll want to carefully read the letter. If you don’t understand the details, you can call Medicare (1-800-MEDICARE) anytime you have a question or concern.

What information might be exposed in a data breach?

The information exposed in a breach of Medicare data will depend on the specifics of the breach. It could involve a variety of PII and/or PHI, including:

• Your name, birthday, and contact information (mailing address, email address, phone number, etc.)
• Your driver’s license or state ID number
• Your Social Security Number or Individual Taxpayer Identification Number
• Your Medicare Beneficiary Identifier (MBI) or Health Insurance Claim Number (HICN)
• Your medical history and medical claims details, including data that appears on a Medicare Summary Notice, details about your medical providers and prescription drugs, etc.
• Your health benefits and enrollment information, including details about Medicare Advantage, Medicare Part D, or Medigap coverage that you may have.

The letter you receive from CMS will explain the type of data that was or may have been compromised.

What can a scammer do with my Medicare number?

Your Medicare Beneficiary Identifier (MBI) is a unique ID number that goes with your Medicare account. If someone else obtains this number, they can use it to file fraudulent claims with Medicare to obtain medical care and equipment in your name.

Fraudulent claims affect both the government and the beneficiary. Medicare fraud, errors, and abuse are estimated to cost the government $60 billion each year.³This is obviously not always due to data breaches: The Medicare Fraud and Abuse handbook focuses almost entirely on medical providers who misuse or abuse the Medicare program. But Medicare identity theft, including identity theft that stems from data breaches, is one of the ways this can happen.

For beneficiaries whose MBI is used fraudulently, the result can be medical bills (deductible, copay, and coinsurance charges) for services they didn’t use, benefit caps being reached despite the person not obtaining services, and erroneous medical records that can be challenging to sort out.

If you receive a medical bill or a Medicare Summary Notice that doesn’t appear correct, you should contact the medical provider for clarification. If you suspect fraud or Medicare identity theft, call 1-800-MEDICARE or contact the Senior Medicare Patrol in your state for guidance.

Scammers use a variety of tactics to get Medicare beneficiaries to divulge their MBI. But these numbers can also be part of a data breach, and the information could be compromised even if the beneficiary doesn’t communicate with the scammer.

Are new Medicare cards being issued for 2023 or 2024?

Most Medicare beneficiaries are not receiving new Medicare cards at this time. However, if your MBI is impacted by a data breach, CMS will mail you a new card that has a new MBI. You’ll continue to use your current Medicare card until the new one arrives. At that point, you should destroy the old one and notify your medical providers that you have a new MBI.

In 2018 and 2019, CMS sent new Medicare cards to all beneficiaries, with new MBIs in place of the previous identification numbers that were based on Social Security Numbers. Those cards continue to be in use, and you do not need a new one unless CMS notifies you that your MBI has been impacted by a data breach.

What is being done to protect my Medicare data?

According to Experian, medical records are among the most valuable assets sold on the dark web, depending on how complete they are. So, Americans’ PII and PHI, including that of Medicare beneficiaries, continues to be a target for data hacks and breaches.

Breaches of Medicare data affect more people each year. In a 26-month period starting in late 2009, CMS notified approximately 14,000 Medicare beneficiaries that their data had been impacted by a breach. The notification process has improved since then, but the scope and number of healthcare data breaches has also grown sharply in recent years,⁴with hundreds of thousands of beneficiaries affected in recent data breaches.

An Office of the Inspector General audit, conducted in 2020, uncovered various cybersecurity weaknesses in the CMS system, all of which were remedied. And the government has taken extensive measures over the last several years to improve cybersecurity in healthcare.

But staying ahead of cyber threats is an ongoing process. A 2022 white paper published by Virginia Senator Mark Warner, notes that Medicare payment formulas need to be adjusted to ensure that the cost of cybersecurity is “reflected in [Medicare] payment formulas the way paying the electricity or water bills are.”⁵CMS and Medicare contractors will need to continue to adapt and evolve on this front, as is the case for all organizations that are vulnerable to data breaches.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written hundreds of opinions and educational pieces about the Affordable Care Act and Medicare for healthinsurance.org and medicareresources.org.

1. ”CMS Confirms 3.1 Million Individuals Affected by MOVEit Hack on Wisconsin Physicians Service” The HIPAA Journal. Sep. 25, 2024
2. “Medicare & You” Medicare.gov, Accessed January 2024
3. “Dollars Lost to Fraud” Senior Medicare Patrol, Accessed December 2023
4. “2022 Healthcare Cybersecurity Year in Review and a 2023 Look-Ahead“ HHS.gov, Feb. 9, 2023
5. “Cybersecurity is Patient Safety” Sen. Mark Warner, November 2022