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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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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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In 1965 President Johnson and the United States Congress created Medicare as part of the Social Security Act. A national program, Medicare is a health insurance program for people 65 years of age or older along with some people under age 65 with disabilities or end stage renal disease. It is broken down into four different parts.

• Part A is hospital insurance – covering expenses for hospital care, nursing facility care, and home health services.

• Part B is medical insurance for outpatient hospital care and doctor’s services. Unlike Part A, Medicare Part B is optional.

• Part C, also known as Medicare Advantage, is a combination of Parts A and B offered by private insurance companies (approved by Medicare) which generally also includes prescription drug coverage.

• Part D is prescription drug coverage, and similar to Part C, is offered by private insurance companies with Medicare approval.

For some people, Medicare covers all of their medical expenses. However, many people have additional out-of-pocket expenses. If you have limited income and resources, you may qualify for help

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Today many Americans find themselves struggling to pay for their medications, unfortunately leading to difficult choices between paying for food, rent, or prescriptions. Luckily pharmaceutical companies and other organizations are aware of this fact, and doing what they can to help alleviate costs for those struggling financially. For many drugs that may seem too expensive to afford there are Patient Assistance Programs (PAPs). These programs offer the drugs at little to no cost to the consumer.

Finding a Program for your Medication:

To apply for a PAP, first make sure one is available for your medication. You can look up each PAP alphabetically on the NeedyMeds site here. There are both brand name and generics listed. Once you find your drug, click on the name of the medication to get to the program details page. Here all of the contact information for the program is listed, along with the application form. You will need to contact the program directly to apply.

Eligibility Requirements:

Every Patient Assistance Program has it’s own set of guidelines and requirements. Most programs require that you are a legal

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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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