Key Takeaways

• Chronic illness management under Medicare in 2025 involves more than just understanding benefits—it’s about anticipating care coordination, coverage gaps, and long-term affordability.

• As an independent agent, your role isn’t just educational; it’s strategic. You need to align Medicare choices with your client’s ongoing health care needs and cost burdens.

Chronic Illness Requires a Medicare Strategy, Not Just a Plan

When a client lives with a chronic illness, Medicare choices take on a deeper layer of importance. Unlike healthier retirees who may only need periodic medical care, clients with conditions like diabetes, heart disease, or COPD interact with the healthcare system frequently. That interaction means more points of risk, more billing, and greater potential for confusion or uncovered services.

Medicare in 2025 has improved in some ways for people with chronic conditions—such as expanded telehealth access and a $2,000 annual cap on prescription drug costs under Part D—but complexity remains. Clients rely on you to interpret what matters most. And what matters is how each Medicare component works for their ongoing care.

Start with the Medicare Basics—But Frame It for Chronic Care

You already know how to explain the ABCs of Medicare. But when you’re advising a client managing chronic illness, standard explanations need to go deeper:

Medicare Part A

• Covers inpatient hospital stays, hospice care, and limited skilled nursing facility care.

• Deductible in 2025: $1,676 per benefit period.

• Most clients qualify premium-free if they worked 40+ quarters.

Make it clear that Part A won’t cover extended stays in rehab or ongoing custodial care for chronic needs. Many clients assume they’ll be covered beyond the short-term scope.

Medicare Part B

• Covers doctor visits, outpatient care, preventive services, and durable medical equipment.

• Standard premium: $185/month in 2025.

• Annual deductible: $257.

For clients managing chronic illness, emphasize:

• Frequent office visits will quickly exceed the deductible.

• Some services may require coinsurance of 20%, which can accumulate fast.

• Coverage for devices like glucose monitors or oxygen may be subject to documentation requirements.

Medicare Part D

• Prescription drug coverage has changed significantly in 2025.

• The coverage gap (donut hole) has been eliminated.

• An annual $2,000 out-of-pocket cap is now in place.

For clients on multiple medications, this is a financial relief. But they need to understand:

• How formularies affect which drugs are covered.

• Why prior authorization may still be a barrier.

• That pharmacies may offer different pricing even within the same plan.

Understanding Coordination of Care in Medicare

Medicare doesn’t coordinate care for the client. That responsibility often falls to the providers—and more often than not, to the client themselves. For individuals with chronic conditions who see multiple specialists, this can lead to disjointed treatment.

What you can do:

• Educate clients about the role of their primary care physician in care coordination.

• Recommend plans (without naming specific providers) that include case management or chronic care coordination programs.

• Emphasize that Original Medicare doesn’t include care coordination unless specifically initiated by a provider.

Be Clear on Out-of-Pocket Exposure

While Medicare covers a broad range of services, chronic illness can lead to high out-of-pocket costs in several key ways:

• Part B Coinsurance: 20% of many services, with no cap under Original Medicare.

• Specialist Visits: Frequent visits mean repeated cost-sharing.

• Lab Tests and Imaging: Common in chronic disease monitoring.

• Therapies: Physical, occupational, or pulmonary therapy may be capped or subject to limits.

• Medications: Even with the $2,000 cap, costs for non-covered drugs or brand preferences can be steep.

Encourage your clients to keep a running estimate of monthly medical expenses—not just premiums.

Help Clients Understand Medicare Advantage Tradeoffs

Some clients with chronic conditions consider Medicare Advantage plans. These often include extra services such as:

• Care coordination teams

• Transportation to medical visits

• Meal delivery after hospitalizations

• Over-the-counter allowances

However, 2025 has seen a reduction in the percentage of plans offering these extras. Fewer plans include transportation and OTC benefits than in 2024. So while clients may be drawn in by advertised benefits, you must:

• Break down whether these benefits are available in your client’s ZIP code.

• Clarify cost-sharing structures, which may include copayments for specialists, diagnostics, and hospital stays.

• Remind clients of the MOOP (Maximum Out-of-Pocket) limits—$9,350 for in-network services, $14,000 for combined in-network and out-of-network.

These caps offer protection, but only once substantial spending has occurred.

Bring Preventive Services Into Focus

Many chronic illnesses can be managed more effectively with preventive care. Medicare fully covers a wide range of these services, including:

• Annual wellness visits

• Diabetes screenings

• Cardiovascular disease screenings

• Smoking cessation counseling

• Vaccinations (flu, COVID-19, shingles, hepatitis B)

Encourage clients to treat these benefits as part of their care plan—not as optional add-ons. Too often, clients skip preventive visits until a flare-up occurs.

Telehealth Has New Relevance in 2025

Telehealth services expanded during the pandemic and remain a covered benefit under Medicare in 2025. For clients with mobility issues, rural residence, or transportation limitations, this can be a game changer.

You can assist clients by explaining:

• Which providers offer telehealth under Medicare.

• That audio-only visits may be allowed for some services.

• Which services must still be provided in person (e.g., certain diagnostics).

This is particularly relevant for clients who need frequent check-ins with specialists or mental health professionals.

Talk Through Durable Medical Equipment (DME)

Clients with chronic illness often rely on devices like oxygen tanks, walkers, or blood glucose monitors. These are covered under Medicare Part B as durable medical equipment, but with caveats:

• Equipment must be medically necessary and prescribed by a physician.

• Suppliers must be Medicare-enrolled.

• Clients are responsible for 20% of the Medicare-approved amount.

Explain that delays can occur in authorization, delivery, or coverage for replacement equipment.

Plan for Hospital Discharges and Post-Acute Care

Hospitalization often isn’t the end of a health event—it’s the beginning of post-acute care. Clients recovering from flare-ups or surgeries may need home health services, physical therapy, or short-term skilled nursing facility care.

Here’s what to explain:

• Medicare Part A covers up to 100 days in a skilled nursing facility, but only after a qualifying 3-day hospital stay.

• After day 20, daily coinsurance applies ($209.50/day in 2025).

• Home health care is covered but must meet certain eligibility conditions.

Clients often misunderstand when coverage ends and when personal funds must begin. This can cause stress during recovery. Clear this up early.

Keep Prescription Drug Costs Visible

The $2,000 Part D cap in 2025 is a major improvement, but clients still need your help managing this benefit throughout the year:

• Make sure their medications are in the plan’s formulary.

• Flag drugs requiring step therapy or prior authorization.

• Help clients understand the Medicare Prescription Payment Plan, which lets them spread drug costs evenly across the year.

Medication management is a huge part of chronic illness control. Any gaps in understanding here can lead to skipped doses or dangerous substitutions.

Know When a Change Is Needed

A client’s health status can shift at any time. What worked last year may not work this year. You should check in:

• Every Open Enrollment (October 15–December 7)

• After major health events (hospitalization, new diagnosis)

• When new benefits become available (e.g., newly covered medications)

Help clients document what’s working and what’s not. They may not even realize what they’re missing until you point it out.

Helping You Support Clients With Chronic Conditions

Supporting Medicare annuitants with chronic illnesses means moving beyond benefit explanations. You are the bridge between a static system and dynamic client needs. Your clients depend on you to:

• Make Medicare feel less overwhelming

• Offer the right level of plan analysis and scenario planning

• Prepare them for out-of-pocket costs

• Identify benefits they may be underusing

At BedrockMD, we help you do that. We equip you with smart tools, detailed plan data, compliance-ready marketing materials, and proven strategies for client engagement. Join us to simplify Medicare and strengthen your business.