Author: DSwisher

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How Your Medical Benefits Work: What Is A Deductible? 

A deductible is a set amount you pay for your health care before your medical plan starts to pay. Once you reach the deductible, you pay a copayment or coinsurance for services covered by your medical plan, and the plan pays for the rest. Generally, the higher the deductible, the lower your premium, and vice-versa. For example, a plan with a $0 deductible may have a higher monthly premium than a plan with a $100 deductible.

The Medicare Part B annual deductible for 2025 is $257. If you are enrolled in the HOP Medical Plan, you are responsible for $50 of that deductible, and the plan pays the rest. The deductible for the Value Medical Plan is $257. If you are enrolled in a Medicare Advantage Plan, call the insurance company phone number on the back of your ID card for your deductible amount.

How It Works

As you incur and pay for medical expenses out of your pocket, the amount you spend counts toward the deductible. Until you reach the deductible, you are responsible for paying 100% of the services covered by your medical plan. Once your out-of-pocket costs reach the deductible amount, your benefit plan will kick in and begin sharing the cost of covered services with you.

For example, the HOP Medical Plan has a $50 deductible. Members enrolled in this plan pay $50 out of their pocket for expenses that are subject to the deductible. Some preventive care services (e.g., annual wellness exams) are excluded from the deductible and covered 100%. After the $50 deductible is met, members share the cost with the Plan through coinsurance or copayments.

Other facts you need to know about deductibles:

  • Some health plans do not have deductibles.
  • The deductible can change from year to year.
  • The deductible resets at the start of every calendar year.
  • Your out-of-pocket costs count toward the deductible.
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Keeping Track of the IRA

Topic list:

Inflation Reduction Act Overview (July 2024)

Have you heard of something called the Inflation Reduction Act (IRA)? If not, that’s OK. This news story breaks it all down for you. Check back for updates between now and the start of the Option Selection Period in October.

What it is: The IRA was signed in August 2022. The Act is a multiyear rollout of governmental changes that affect how Medicare coverage works. Some of the changes benefit the government, some benefit plan administrators, and others benefit the plan participants.

Why it is important: The IRA changes affect all Medicare prescription drug plans, including the Health Options Program. Starting in 2025, the government is requiring changes that will significantly change Part D plan designs, for example, the Coverage Gap is being eliminated, and there will be a $2,000 TrOOP maximum for Medicare Part D prescription drugs.

What it means to you: If you are enrolled in the Health Options Program, your current benefits will continue through December 31, 2024. The Health Options Program is carefully reviewing the requirements of the IRA and what they mean for future plan designs. As the 2025 Option Selection Period gets closer, we will keep you updated with what you need to know. If you are enrolled in another plan, reach out to their customer service team with questions.

Inflation Reduction Act Recap (August 2024)

This article provides a quick recap of changes already made. For example, did you know that the IRA was responsible for reducing the cost of insulin and offering no-cost vaccines in 2023? Since then, the IRA has been responsible for other changes to help control costs, as shown below.

In general, the changes are shifting how drug costs are shared across plan participants, drug manufacturers, the federal government, and prescription drug plans. There are more changes to come in 2025, with prescription drug plans paying an even larger share of costs than they do today. More information about how these will affect your plans in 2025 will be provided as the Option Selection Period starts this fall.

Timeline of IRA Changes in 2023:

  • Plan participants pay less at the pharmacy for insulin ($35 maximum) and nothing for certain vaccines.
  • Drug manufacturers pay rebates to the federal government (Medicare) if
    drug costs increase more than the rate of inflation.

Timeline of IRA Changes in 2024:

  • Plan participants pay nothing for drugs once they reach the catastrophic tier.
  • Plans are picking up a higher share of the cost for drug claims after participants reach the catastrophic tier.

The Medicare Prescription Payment Plan in 2025 (September 2024)

The Medicare Prescription Payment Plan is a new payment option to help plan
participants manage out-of-pocket drug costs, starting in 2025. This new
payment option works with your current drug coverage, and it can help manage
drug costs by spreading them across monthly payments that vary throughout the year (January–December). This payment option might help you manage your expenses, but it doesn’t save you money or lower your drug costs.

Extra Help from Medicare and help from your SPAP and ADAP, for those who
qualify, is more advantageous than participation in the Medicare Prescription
Payment Plan. All members are eligible to participate in this payment option,
regardless of income level, and all Medicare drug plans and Medicare health
plans with drug coverage must offer this payment option.

In November, Optum Rx, the prescription drug plan administrator for the
Health Options Program, will send more information to members who are likely to benefit from this payment plan. The letter will provide more information about how it works. If you have questions after reviewing the information, contact Optum Rx at 1-888-239-1301 (TTY/TDD: 1-800-498-5428).

If you are enrolled in a Medicare Advantage plan, contact the plan for additional information. You can also visit medicare.gov to learn more.

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What Happens to Your Medical Coverage if You Travel or Live in 2 States?

Are you over 65 and traveling within the United States?

  • Both the HOP Medical Plan and the Value Medical Plan offer flexibility if you travel or divide your time in two (or more) cities or states within the United States. This is because the HOP Medical Plan and the Value Medical Plan allow you the freedom to use virtually any health care provider (doctor or hospital) you want.
  • A Medicare Advantage plan is designed for where you live, so you’ll need to use its network of providers to receive maximum benefits. Check with your Medicare Advantage plan on how they cover services if you are away from home, so there are no surprises!

Are you over 65 and traveling outside the United States?

  • If you are eligible for Medicare and enrolled in the HOP Medical Plan, you’re covered anywhere in the United States and abroad when you are traveling. The HOP Medical Plan gives you the most coverage and flexibility if you travel out of the country.
  • If you’re enrolled in the Value Medical Plan, coverage for services provided abroad is limited to those covered by Medicare. Covered expenses are subject to Medicare’s Major Medical Deductible and copay amounts.

Are you under 65?

If you are not eligible for Medicare, the HOP Pre-65 Medical Plan uses Private Healthcare Systems (PHCS), a national network of health care providers. Each time you need medical care, you can decide whether to use an in-network or out-of-network provider. While you are free to go out-of-network whenever and as often as you like, using a PHCS network provider is your lowest-cost option. You can receive reimbursement for out-of-country medical expenses.

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