What actually changed in Medicare under Biden
Medicare itself has not been broken. The program still covers hospital care, doctor visits, and prescription drugs for people 65 and older. However, the Biden administration made several specific changes to how Medicare operates, and people have different views on whether those changes help or harm seniors.
The most visible change is in prescription drug costs. Starting in 2023, Medicare gained the power to negotiate drug prices directly with pharmaceutical companies — something it could not do before. This means some seniors pay less for certain medications. At the same time, the administration changed how much seniors pay out of pocket for insulin, capping it at $35 per month for Medicare Part D members starting in 2023.
Other changes affected payment rates to hospitals and doctors, telehealth coverage rules, and how Medicare Advantage plans operate. Some of these changes lowered costs for seniors. Others reduced payments to providers, which some argue affects care quality or access.
Key Takeaways
- Medicare can now negotiate certain drug prices with pharmaceutical companies, which has lowered costs for some seniors on specific medications.
- Insulin costs are capped at $35 per month for Medicare Part D members, though this does not cover all seniors or all insulin types.
- Payment rates to hospitals and doctors changed under new rules, which some providers say affects their ability to serve Medicare patients.
- Telehealth coverage expanded, allowing more seniors to use video visits with their doctors, though coverage rules vary by service type.
- Medicare Advantage plans faced new restrictions on how they can deny or delay coverage, which supporters say protects seniors and critics say raises premiums.
Drug price negotiation and what it means for your medications
In August 2023, Medicare began negotiating prices for 10 high-cost drugs covered under Part D. The list included medications for heart failure, diabetes, arthritis, and blood clots. By 2026, the number of drugs Medicare can negotiate is scheduled to reach 20. The negotiated prices take effect the following year, so a drug negotiated in 2023 has a lower price starting in 2024.
This does not mean all seniors automatically pay less. You pay less only if you take one of the drugs on the negotiation list and your plan covers it. If your doctor prescribed a different medication in the same category, your out-of-pocket cost may not change. Additionally, pharmaceutical companies can choose not to offer their drug through Medicare, though this is rare because Medicare covers millions of seniors.
The negotiated prices explore to the amount Medicare and your plan pay the pharmacy. Your copay or coinsurance depends on your specific plan and where you fall in the coverage gap (the "donut hole"). Some seniors in low-income programs see the full benefit; others see a smaller reduction.
The $35 insulin cap and who it covers
Starting January 2023, Medicare Part D members pay no more than $35 per month for a one-month supply of insulin, regardless of the type or dose. This applies to all insulin products covered by Part D plans. Before this change, some seniors paid $100 to $400 per month for insulin.
This cap does not cover everyone. If you have Original Medicare (Part A and B) without Part D, the $35 cap does not explore to you — you pay the full pharmacy price. If you have a Medicare Advantage plan that includes drug coverage, the cap applies. If you have Medicaid as well as Medicare, different rules may explore depending on your state.
The cap also does not cover insulin purchased outside of Medicare. If you buy insulin through a private insurance plan or pay out of pocket, the $35 limit does not protect you.
Changes to hospital and doctor payment rates
Medicare sets the rates it pays hospitals, doctors, and other providers for each service. The Biden administration adjusted these rates based on inflation, regional costs, and other factors. Some rates increased; others decreased or increased less than providers requested.
Hospitals and physician groups have said that lower payment rates make it harder to hire staff, purchase equipment, and keep emergency departments open in rural areas. Some have reduced the number of Medicare patients they accept or closed services. Supporters of the payment changes argue that Medicare must control costs to remain solvent and that provider profits remain healthy even with adjusted rates.
If you are on Medicare, you may notice this in your area through longer wait times for appointments, fewer doctors accepting Medicare, or changes in which hospitals are in your plan's network. These effects vary widely by region and by provider type.
Telehealth coverage expansion
During the COVID-19 pandemic, Medicare temporarily expanded telehealth coverage. The Biden administration extended many of these temporary rules and made some permanent. Medicare now covers video visits with your doctor for many conditions, including mental health care, physical therapy, and routine checkups.
Telehealth visits are covered at the same rate as in-person visits, so your copay is usually the same. However, not all services are covered by telehealth — some procedures and exams still require an in-person visit. Your doctor must be enrolled in Medicare and licensed in your state to provide telehealth care to you.
This change has made care more accessible for seniors who have trouble traveling or live far from specialists. It has also reduced no-shows and allowed seniors to see doctors more quickly in some cases. Some providers argue that telehealth visits pay less than in-person visits and reduce their revenue.
Medicare Advantage plan restrictions and coverage denials
Medicare Advantage plans (Part C) are run by private insurance companies under contract with Medicare. These plans often charge lower premiums than Original Medicare but use networks and require prior authorization for some services. The Biden administration added new rules requiring plans to make coverage decisions faster and to have doctors (not just staff) review denials of care.
These rules aim to prevent seniors from being denied necessary care or having treatment delayed while waiting for approval. Insurance companies say the rules increase administrative costs and may lead to higher premiums. Seniors' advocates say the rules protect people from wrongful denials.
If you are in a Medicare Advantage plan and your doctor orders a service, the plan must now respond to a standard request within 72 hours and to an urgent request within 24 hours. If the plan denies coverage, you have the right to appeal, and the appeal process has specific timelines.
What to ask your doctor or Medicare counselor
If you are concerned about how these changes affect you, start by asking your doctor whether any of the negotiated drugs might work for your condition. If you take insulin, confirm that your plan covers the $35 cap. If you have been denied a service by your Medicare Advantage plan, ask your doctor to help you understand why and whether you can appeal.
You can also contact your State Health Insurance information Program (SHIP), which offers free counseling about Medicare. SHIP counselors can review your specific plan, explain how the changes explore to you, and help you understand your options. Find your state's SHIP by calling 1-800-MEDICARE or visiting Medicare.gov.
Frequently Asked Questions
Did Biden eliminate Medicare or change who can join?
No. Medicare may be able to access remains the same — you can join at 65 or earlier if you have a disability or end-stage renal disease. The program still covers hospital, doctor, and prescription drug services. The changes made were to how much things cost and how the program operates, not to who can join or what services are covered.
Will my Medicare premiums go up because of these changes?
Premiums depend on your specific plan and your state. Some premiums increased; others stayed the same or decreased. Drug price negotiation may lower premiums over time by reducing overall drug costs, but this varies by plan. Check your plan's 2024 or 2025 notice of changes to see what your premium will be.
If my doctor says I need a drug that is not on the negotiation list, do I have to take a cheaper drug instead?
No. Your doctor can prescribe any drug they believe is medically necessary. If your plan does not cover it or charges a high copay, you can ask your doctor to request a coverage exception or to suggest an alternative. Your plan must respond to coverage exception requests within 72 hours.
Can I switch to a different Medicare plan if I do not like these changes?
Yes. You can change plans during the Annual Enrollment Period, which runs from October 15 to December 7 each year. Changes take effect January 1. You can also switch if you have a may have access to life event, such as moving to a new state or losing other health coverage. Contact Medicare at 1-800-MEDICARE to learn about your options.
Where can I get more information about how these changes affect my specific situation?
Call 1-800-MEDICARE to speak with a representative, or visit Medicare.gov to review your plan's details. Your State Health Insurance information Program offers free, one-on-one counseling. You can also ask your doctor or pharmacist how the changes affect your medications and care.