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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Many of our NeedyMeds users have asked us to help them figure out what healthcare reform, or Obamacare, will mean for them and for their families or clients.  This is understandable because the law is complex, with both state and federal governments playing a role in implementation.

Some of the more common questions include these:

  • I am uninsured right now. The new law says I have to buy insurance. What happens if I can’t afford it? What will happen if I don’t buy it?
  • Can I keep the health insurance I already get from my work?
  • Can I get health insurance even if I already have health problems?
  • I am a senior citizen. What will happen to my health coverage with the new law?

To help answer these and other questions, and provide clear guidance, we recommend reading Kaiser Health News’ “A Consumer’s Guide To The Health Law,” which provides a clear and concise overview of the ACA.

Some analysts argue that there could be modifications to reduce federal spending as part of a broader deficit deal; for now, this is just speculation. What is clear is that the law will have sweeping ramifications for consumers, state officials, employers and health care providers, including hospitals and doctors.

While some of the key features don’t kick in until 2014, the law has already altered the health care industry and established a number of consumer benefits. For example, the extension of coverage to adult children up to age 26, the elimination of lifetime spending caps and ability

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