Market upheaval involves Medicare Advantage and Part D coverage
Medicare recipients in New Hampshire are in what’s being described as a disruptive enrollment period as insurance carriers have changed plans, exited certain counties, or decided to leave the state altogether.
The upheaval in the market has to do with the Medicare Advantage, known as Plan C, offerings by private insurance companies.
About 44,000 seniors in New Hampshire — more than half of the state’s Medicare Advantage population — need to choose a new plan or carrier for 2025.
Advantage plans bundle Medicare Part A (hospital insurance), Part B (medical insurance), and usually Part D (drug coverage) into one plan that often includes extra benefits such as vision, hearing, dental, and/or health and fitness/wellness programs.
Chris Cote, president of Core Benefits Group in Londonderry, describes the current situation as “very, very hectic.”
“Unfortunately for New Hampshire, it’s kind of a perfect storm,” said Cote, an independent broker who helps individuals and businesses find the right insurance plan in which to enroll. “So there’s a lot of disruption.”
That’s because, according to information supplied to Cote and other brokers, as well as data provided by the state Insurance Department: Three carriers (Aetna, UnitedHealthcare, and Martin’s Point) are charging more for their plans. Martin’s Point, for example, is going from zero dollars each month to $29; Aetna’s increase is going from $0 to $47 a month; Aetna will no longer offer its Advantage plans in Coos County and is dropping its fitness benefit on all plans; and Humana, with 200 members impacted, is pulling out of Coos County.
In addition, Harvard Pilgrim Health Care and Wellcare (Centene) will no longer offer any Medicare Advantage plans in 2025, affecting some 16,000 people.
A nationwide shift
“Reviewing options carefully, verifying provider networks, and making timely decisions will be key to minimizing disruptions and ensuring continued access to the health care services they need in the year ahead,” said Insurance Commissioner D.J. Bettencourt.
The Insurance Department issued an advisory saying that seniors currently enrolled in Medicare Advantage plans that are being discontinued will need to select a new Medicare Advantage plan if they wish to remain enrolled in an Advantage plan. If they do not actively choose a new Advantage plan by the date that their current plan terminates, they may be automatically reverted to original Medicare.
According to Bettencourt, the upheaval in the Granite State is part of a broader, nationwide shift driven by rising health care costs and recent federal decisions impacting Medicare funding.
“Since Medicare Advantage plans are regulated by the federal government, these disruptions are not unique to New Hampshire but are being felt across the country,” said Bettencourt.
“It is critical for consumers to act quickly, especially those whose plans are being discontinued, to avoid any gaps in coverage,” he added. “Seniors must also ensure they have the necessary prescription drug coverage in place to prevent potential penalties.”
In 2023, according to healthinsurance.org, 332,438 New Hampshire residents had Medicare coverage, which is about 24% of the state’s population. This is higher than the national average of nearly 20%.In response to its eliminating an Advantage plan in the state, Harvard Pilgrim said in a statement: “We continuously examine our business to ensure we offer our members affordable, high-quality health plans and products in the market. After a careful analysis, we made the difficult decision to discontinue our Harvard Pilgrim Stride (HMO/HMO-POS) Medicare Advantage plan in New Hampshire effective Jan. 1, 2025.”
But it also stressed it is not completely exiting the New Hampshire market, saying, “We will continue to offer a Harvard Pilgrim Medicare Supplement plan and our Harvard Pilgrim commercial products for employer groups and plans on the New Hampshire exchange.”
Wellcare announced it will discontinue offering Advantage products in New Hampshire, as well as Alabama, Massachusetts, New Mexico, Rhode Island and Vermont in 2025, saying the decision was made to better focus their strategy and resources. It will retain its Part D prescription drug plan.
The Harvard Pilgrim exit is especially acute, affecting 10,000 seniors who now have to look elsewhere for an Advantage plan.
“Harvard Pilgrim, unfortunately, they decided to exit the Medicare Advantage market in New Hampshire for 2025, and they had a really good product,” said Cote. “Their plan wasn’t performing up to their standards, I guess you could say. It’s just been, obviously the biggest upheaval for us, where now all those customers have to find a new plan for 2025.”
The upheaval is primarily due to a change in the Part D coverage for prescription drugs.
Prescription medicine coverage
For years, seniors have had a gap in their coverage of prescription medicine, which, depending on the drug, can be quite a large out-of-pocket expense. If you exceeded your $3,000 insurance cap, you started paying out of pocket for prescription drugs. Only after reaching an $8,000 threshold did catastrophic coverage kick in. That out-of-pocket gap of $5,000 is the doughnut hole.
The federal Inflation Reduction Act of 2022 reduced the Part D threshold to $2,000, which means that once someone reaches the $2,000 in out-of-pocket spending on covered drugs, they automatically qualify for catastrophic coverage and won’t have to pay out-of-pocket for the rest of the year.
“It’s a good thing for consumers, but the problem on the back end is who’s going to pay for that difference? What ends up happening is the insurance companies are actually having to foot most of that bill,” said Cote. “That’s why you’ve seen changes to your plan.”
While some companies are exiting counties or the state, another company, WellSense, is coming into the state with a first-time Advantage PPO plan. With a Preferred Provider Organization (PPO) plan, subscribers can use a network of doctors, hospitals and other health care providers; it also allows use of providers outside of the network but usually at a higher cost.
“This is the first year we’ve offered a PPO,” said Paul Wingle, chief product and sales officer at WellSense. “And 54% of Medicare Advantage consumers in New Hampshire choose a PPO. So we wanted to make sure we were adding something to the shelf that would appeal to Granite Staters, and that was an important gap for us to close, to increase our appeal and to serve the interests of the market.”
WellSense, which serves Massachusetts and New Hampshire and was formerly branded as Boston Medical Center HealthNet Plan, has offered other medical insurance plans in the Granite State but the Medicare Advantage PPO in 2025 is a first.
“The timing is really fortuitous,” said Wingle, “because a lot of the other plans are pulling back, and we want to make sure that folks in the Granite State have a good PPO option they can rely on, as other carriers make moves to exit or reduce benefits or increase their prices.”
By law, seniors were to have been notified of changes in their plans by Oct. 15. The enrollment period runs until Dec. 7 to change their plan.
Medicare Advantage plans remain an option in the state. Another option is a Medicare Supplement, also known as Medigap, plan. That is a health insurance policy that helps pay for out-of-pocket costs that original Medicare doesn’t cover. These individual plans can help pay for services such as dental, vision and prescription drugs.
Seniors looking at a change because their premium has gone up, or because their plan isn’t provided anymore, should get as much information as they can about their options, according to Cote.
“Definitely contact your broker, and if you don’t have a broker, try to find one,” said Cote. “Some agents hold seminars, educational meetings and things like that. Community centers have educational meetings, and usually those are run by someone like me, an independent agent who will do a presentation.”
In addition to independent brokers such as Cote, the state Department of Health and Human Services provides Medicare information online, and more information is available from the state Insurance Department.
