Tag: Donut Hole

The Donut Hole is Closed!

The year 2019 is here, and there is some good news to those who have had experience with the Medicare Part D “donut hole.” Since the passage of the Affordable Care Act in 2010, the “donut hole” has been on track to close by 2020. Due to the passing of the Bipartisan Budget Act of 2018, which stopped last year’s nine-hour shutdown of the federal government, the Part D “donut hole” has actually closed a year ahead of schedule.

Medicare, one of the publicly funded health insurance programs for people over 65 or people younger than 65 with a qualifying health condition, is divided into four parts. This can be confusing for those who are newly eligible trying to find what the differences are and what benefits they will end up having.

Medicare Part A is hospital insurance. This part of Medicare provides you a place to stay with meals while you receive medical services whether at a hospital, hospice, or skilled nursing facility.

Medicare Part B is for medically necessary outpatient procedures. This covers a portion of doctor office visits, lab testing, diagnostic imaging, preventive

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All About Government Programs

One often overlooked resource on the NeedyMeds website is our listings of Government Programs. These programs are state-specific, and help needy families and individuals with the cost of healthcare. We regularly update this database, which includes State-Sponsored Programs, Medicare Information, Medicaid Sites, State Health Insurance Assistance Program information, and Federal Poverty Level and Tax Return Request Form guidelines and information. If you are not having luck finding a PAP or co-pay program for your medication or particular disease, there may be a Government Program there to help.

State Sponsored Programs

Programs that are created, sponsored, or funded by a state, county or local government are considered State Sponsored Programs. These programs provide a variety of types of assistance ranging from medical care, financial assistance, health insurance, prescription assistance, assistance with medical supplies and much more. We list these programs on our website by state. Simply choose your state from the drop-down menu

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The Affordable Care Act and the Future of Assistance Programs

We’ve been getting a lot of questions from our readers about how the resources we list on our website, especially the pharmaceutical patient assistance programs, will be affected by the Affordable Care Act. While we are still far away from having all the answers, we do have some additional information we can provide you after attending a recent PAP Conference. The overarching consensus is that PAPs will continue to exist to help those in need that fall into the gaps.  Here is an overview of what we learned at the CBI PAP 2014 Conference, held in Baltimore on March 6-7.

Background

→ There are currently no shared processes between programs.

→ Open Enrollment ends March 31st

  • Negative image of Affordable Care Act in the media.
  • For those working with the disabled – visit the National Disability Navigator Resource Collaborative for resources http://www.nationaldisabilitynavigator.org.
  • Many advocates are having trouble enrolling the population that has been uninsured for a long time, as they are not informed about how health insurance works at all.

→ Medicaid Donut Hole

  • In the states that have not expanded Medicaid, there are going to be folks too poor to be eligible for subsidies under the marketplace and not poor enough to qualify for Medicaid in their states.

→ Not everyone between 100% and 400% of Federal Poverty Level are eligible for subsidies. This, for example, can depend on age.

Pharma Priorities and Considerations

→ Priorities are to contain costs, increase quality, encourage innovation while enhancing patient access.

→ Legal Considerations.

  • Anti-kickback statute – always a legal issue for companies. Pharmaceutical companies cannot induce (or even appear to induce) patients to use a certain drug.
  • November 2013
    • HHS Secretary Kathleen Sebelius wrote a letter saying that plans purchased on a state or federally run market place are not counted as government sponsored programs.
    • Absent further guidance – these plans are going to be treated as private plans by Patient Assistance Programs (PAPs), foundations, etc.

    → Lingering question – what happens when someone doesn’t pay or defaults on their premium? There is currently a grace period to

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What on Earth is the Donut Hole? A Brief Explanation of Medicare Part D and the “Donut Hole”

Today, we are hoping to provide answers to some of your questions about the Donut Hole! Tell us about your experiences. We would love to hear from you.

 1.    What is the donut hole? To answer that question, we first need to understand Medicare and Part D.

According to Jonathan Blum, Deputy Administrator and Director for the Center of Medicare at the Centers for Medicare and Medicaid Services, Medicare is the federal health insurance program for people 65 or older, people under 65 with certain disabilities, and people with End-Stage Renal Disease (permanent kidney failure).  People with Medicare have the option of paying a monthly premium for outpatient prescription drug coverage. This prescription drug coverage is called Medicare Part D.

Basic Medicare Part D coverage works like this:

  • You pay out-of-pocket for monthly Part D premiums all year.
  • You pay 100% of your drug costs until you reach the $310.00 deductible amount.
  • After reaching the deductible, you pay 25% of the cost of your drugs, while the Part D plan pays the rest, until the total you and your plan spend on your drugs reaches $2970.00.
  • Once you reach this limit, you have hit the coverage gap referred to as the “donut hole,” and you are now responsible for the full cost of your drugs until the total you have spent for your drugs reaches the yearly out-of-pocket spending limit of $4,550.
  • After this yearly spending limit, you are only responsible for a small amount of the cost, usually 5% of the cost of your drugs.

2.    What is the structure, e.g., cut-offs, coverage amounts and patient payment percentages?

The “donut hole” refers to a gap in prescription drug coverage under Medicare Part D. In, 2013, once you reach $2,970 in prescription drug costs (which include both your share of covered drugs and the amount paid by your insurance), you will be in the

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About Us

Welcome to the NeedyMeds Voice! We look forward to presenting you with timely, provocative pieces on healthcare reform, patient advocacy, medication and healthcare access, and other health-related news. Our goals are to educate, enlighten, and elucidate; together, we will try to make sense of the myriad and ongoing healthcare-related changes in the U.S. today.