The Biggest Medicare Rule Changes for 2023

Medicare undergoes changes each year to adjust costs, benefits, and coverage. However, 2023 marks one of the most significant years for adjustments to the Medicare program. This article will explain the most notable Medicare rule changes going into effect in 2023.

Part A Cost Changes

Medicare Part A covers hospital insurance services, including inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care services. Here are the Medicare Part A cost changes for 2023:

• Inpatient Hospital Deductible: The Part A deductible for each benefit period will increase by $44 to $1,600 in 2023. This is the amount a beneficiary must pay out-of-pocket before Medicare Part A coverage kicks in for a hospital stay.

• Daily Coinsurance for Days 61-90: The daily coinsurance amount for hospital stays lasting 61-90 days will remain $400 per day in 2023.

• Daily Coinsurance for Lifetime Reserve Days: The daily coinsurance for each Medicare Lifetime Reserve Day will stay at $800 per day for 2023. Lifetime reserve days are additional days that Medicare Part A covers when someone’s hospital stay exceeds 90 days. There are a total of 60 reserve days available in one’s lifetime.

• Skilled Nursing Facility Coinsurance: The skilled nursing facility coinsurance will remain $200 per day for days 21-100 of a stay in 2023.

• Part A Premiums: The standard monthly premium for Medicare Part A for those who must pay it will increase by $7 to $506 per month in 2023. Most people do not pay a premium for Part A coverage since they or their spouse paid Medicare payroll taxes for at least 10 years.

Part B Cost Changes

Medicare Part B covers outpatient medical services like doctor visits, preventive care, lab tests, durable medical equipment, and more. Here are the notable Part B cost adjustments for 2023:

• Part B Premiums: The standard monthly premium for Medicare Part B will decrease to $164.90 in 2023, down from $170.10 in 2022. Most beneficiaries will pay this standard amount, but higher-income enrollees do pay more.

• Part B Deductible: The annual deductible for Medicare Part B is decreasing by $7 to $226 in 2023. This is the amount a beneficiary must pay out-of-pocket for Part B services before Medicare coverage kicks in.

• Excess Charges for Non-Participating Providers: If a doctor does not accept Medicare assignment, they can charge up to 115% of the Medicare-approved amount. The limiting charge amount will decrease to 115% in 2023 from 124.5% in 2022 for most services. This helps protect beneficiaries from excessive charges from non-participating providers.

Part C (Medicare Advantage) Changes

Medicare Advantage plans are private plan alternatives to original Medicare offered by insurance companies. Here are some notable adjustments impacting Medicare Advantage for 2023:

• Maximum Out-of-Pocket Limits: The maximum out-of-pocket spending limits for in-network Medicare Advantage services will increase to $8,300 in 2023 from $7,550 in 2022. This provides financial protections for beneficiaries enrolled in MA plans.

• Enhanced Benefits: Medicare Advantage plans have the option to offer enhanced benefits beyond what original Medicare covers, like vision, dental, hearing, transportation, and more. More plans will offer these enhanced benefits in 2023.

• Special Needs Plan Eligibility: The eligibility criteria for certain Special Needs Plans (SNPs) focused on vulnerable populations will expand to allow more people to enroll in 2023. For example, more institutional level of care criteria will qualify someone for an Institutional SNP.

• Plan Options: Medicare Advantage plan offerings continue to increase nationally, giving Medicare beneficiaries more options to choose from. An estimated 93% of people with Medicare will have access to 10 or more Medicare Advantage plans in 2023.

Part D (Prescription Drug Coverage) Changes

Medicare Part D is the program’s prescription drug benefit offered through private insurance plans. Here are the main Medicare Part D adjustments for 2023:

• Deductibles: The maximum deductible that Part D prescription plans can charge will increase by $25 to $505 in 2023. Many plans do charge below this maximum amount, so check individual plan details.

• Initial Coverage Limit: The initial coverage limit, up to which beneficiaries pay copays or coinsurance, will increase to $4,660 in 2023 from $4,430 in 2022.

• Insulin Copays: Copays for covered insulins will be capped at $35 for a 30-day supply starting in 2023. This applies even during the deductible stage.

• Vaccine Costs: Vaccines recommended by the CDC will be covered at no cost under Part D starting in 2023. This includes vaccines like shingles.

• Out-of-Pocket Threshold: The out-of-pocket spending threshold to qualify for catastrophic coverage will increase to $7,400 in 2023 from $7,050 in 2022.

• Cost Sharing in Catastrophic Phase: Brand name drug copays in the catastrophic coverage phase will increase to $4.15 for generics and $10.35 for brand names. Applies to plans without additional coverage in the gap.

• Drug Manufacturer Discounts: Brand name drug manufacturers will owe Medicare a rebate when they increase prices faster than inflation. This starts to apply in 2023.

Telehealth Expansion

During the COVID-19 public health emergency, Medicare greatly expanded access to telehealth services to improve access. Some of these telehealth expansions will remain in effect for 2023:

• Medicare will continue to cover audio-only telehealth visits in 2023. Pre-pandemic, only video visits were allowed.

• More types of healthcare providers will be permitted to offer telehealth services in 2023, including physical therapists, occupational therapists, and others.

• Medicare Advantage plans have more flexibility to offer additional telehealth benefits in 2023. More plans may provide things like tele-mental health services.

• However, other expanded telehealth benefits will sunset once the public health emergency ends, likely at some point in 2023. These include telehealth coverage for new patients and more telehealth coverage in the home.

Enrollment and Eligibility Changes

Medicare also made changes to enrollment rules and procedures for 2023:

• No More Waiting Periods: Starting in 2023, people who enroll during Medicare’s open enrollment windows will not have a gap in coverage. Their Medicare start date will be the first of the month after they enroll.

• New Special Enrollment Periods (SEPs): Medicare has established new SEPs for 2023 for certain situations like losing employer coverage, losing Medicaid coverage, being affected by a natural disaster, and more.

• Medicare.gov Enrollment Improvements: The Medicare.gov website will offer enhanced tools to compare plans and pricing. Beneficiaries can use filters and side-by-side comparisons to best select their coverage.

• Medicare Card Redesign: New Medicare cards issued as of 2023 will have larger font sizes to improve readability for seniors. Information will be easier to read.

Preventive Care Improvements

Medicare also expanded access to certain preventive services and screenings in 2023:

• Diabetes Prevention Program: Medicare will directly reimburse program providers for the CDC-approved Diabetes Prevention Program beginning April 1, 2023. This helps beneficiaries prevent or delay type 2 diabetes.

• Screening and Counseling Services: Medicare will add more Healthcare Common Procedure Coding System (HCPCS) billing codes for the Annual Wellness Visit, allowing doctors to better track and offer preventive counseling services focused on things like advance care planning.

• Colorectal Cancer Screening: Medicare will now fully cover a screening colonoscopy once every 10 years (previously was once every two years) when a beneficiary is at normal risk for colorectal cancer. This improves access to this preventive service.

Behavioral Health Enhancements

Finally, Medicare also expanded coverage of mental and behavioral healthcare services for 2023:

• Co-Locating Behavioral Health in Primary Care: Medicare will pay primary care practices to integrate behavioral health providers into the primary care setting to improve access to mental healthcare.

• Opioid Treatment Programs (OTPs): Medicare will pay for OTPs to provide mobile medication units to expand access to opioid treatment, particularly in rural areas.

• Certified Community Behavioral Health Clinics (CCBHCs): Medicare will allow CCBHCs to expand the mental health and substance use disorder treatment services they can provide to Medicare beneficiaries.

• Tele-Mental Health Services: Medicare Advantage plans have greater flexibility to offer telehealth services for mental health and substance abuse treatment. This expands access.

The Bottom Line

While details vary, the overarching goals for Medicare’s 2023 rule changes are to:

• Reduce costs for beneficiaries through things like lower Part B premiums and the cap on insulin copays