The Medicare Checkup Nobody Told You About | Insights Beyond the Counter

SPEAKER_1 (0:05)

You are listening to the global network of podcasters dedicated to the pharmacy profession. Welcome to the Pharmacy Podcast Network.

In this episode of Insights Beyond the Counter, experts from Outcomes and Healthpilot break down Medicare in simple terms, explain why annual plan reviews matter, and discuss the key changes coming in 2027 that could affect health care and prescription costs. Here's today's host, Megan Urban.

Megan Urban (0:49)

Hello, and welcome back to Insights Beyond the Counter. I'm Megan Urban from Outcomes, and today we're talking about something that's likely to impact almost every single pharmacy in the country over the next year, Medicare. Now, let's be honest, when most people hear the word Medicare, they immediately think paperwork, regulations, and a lot of complexity. But what happens in Medicare doesn't stay in Medicare. It shows up at the pharmacy counter, it affects what patients can afford, the questions they're asking your staff, and even the opportunities pharmacies have to improve outcomes and grow clinical services.

January is right around the corner.

As we look ahead to 2027, there are some important trends taking shape. Beneficiaries are navigating new coverage policies, plan options continue to evolve, and some pharmacies are increasingly finding themselves in the middle of helping patients understand what that means.

Pharmacies are acting as a translator these days. To help us break it down, I'm joined today by Dave Nicklaus from Healthpilot. Healthpilot works closely with Medicare beneficiaries every single day, helping them make informed coverage decisions and understand their options. We also have Rose Firitani from Outcomes. She's one of our product owners and subject matter experts. Dave, Rose, thank you for joining us today. Set the table for us, Dave. What's actually different about Medicare going into 2027?

Dave Nicklaus (2:20)

Yeah. Thanks, Megan. I really appreciate the opportunity to be here today.

It's interesting because there's not a lot that's going to be necessarily different from 2026 to 2027 We've actually seen disruption now for two years in a row.

Last year, many seniors felt the disruption for the first time in Medicare. Medicare for many, many years was just advantageous for our seniors in Medicare. They got a lot of new things. They got a lot of new over-the-counter medications, they got a lot of new lower co-payments. Medicare was always really just in favor of the consumer. But last year for the first time, due to carrier pressures, we saw some degradation to services and benefits for the seniors. That same trend is going to continue in an even bigger way in 2027 Just an example, there's about 29 million people that are on Medicare Advantage plans today.

Out of those 29 million people, what we've seen in the data for January 1st of 2027, about 5.2 million of those people are going to have their plan completely change. Some of them are going to just, it's going to be called a service area reduction. Their plan just goes away. It's just gone. So what they've known in 2026 is gone and no longer for 2027 And they're going to be thrown into the Medicare Ocean to sink or swim.

Many of those 5.2 million people, the carriers are going to do what they say they call crosswalk. They're going to offer a new plan, but it's not the same plan they've had. And so they're just going to migrate them over and send them a letter and say, hey, your old plan went away, but you now got a new one. Make sure you look at it because it's a little bit different. And so those 5.2 million people, that's one in five seniors on Medicare, are going to have a really massive change. And many of them may not be fully aware of how that impacts them or how it doesn't impact them. So it's going to be a real change for the seniors in Medicare this year, for the second year in a row.

Megan Urban (4:11)

And I think it's really important for pharmacists to be prepared for those changes. So let's get specific. Rose, what does a pharmacist actually see change at the pharmacy counter?

Rose Firitani (4:23)

Yeah, so when January 1st, 2nd hits, right? Patients are just, they're kind of coming through the door expecting their refills, their new medications, they're going to be filled. They're expecting no hiccups, right? They're assuming that, well, I didn't change my plan, but quite honestly, the plan was good enough for me, so I went ahead and went with what I had.

Pharmacy is going to take their new insurance cards or maybe any updated information, process those prescriptions, and to their surprise, they might see a hard reject, right? They're going to see something from the insurance that says either medication's not covered, a PA is required. In some instances, some pharmacies will see that they're no longer a network and their patients can't even fill out their pharmacy. They may have gone to those pharmacies for years, and it kind of stinks at that point, right? Patients are kind of stuck in this, well, what am I supposed to do? They've got to now transfer their prescriptions out, they've got to go to a different pharmacy that they are not familiar with, and see if that pharmacy will actually cover those meds or cover them as a patient, right, with the new plan.