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Medicare Donut Hole Gets Smaller

11/9/2010 2:30pm

Changes are coming for those with Medicare Part D Prescription Drug coverage. These revisions, brought about by the Affordable Care Act (ACA), include reductions in the donut hole which will cut back on costly medication expenses. The new adjustments will take effect in 2011, but decisions on coverage have to be made between November 15 and December 31.

The Part D coverage gap (donut hole) is like a second deductible in the middle of the year for those with high prescription drug costs.  In 2011 individuals will reach the coverage gap after the full costs of their prescriptions for the year reaches $2,840.

In the past, once that amount was reached, individuals would be required to pay the full cost for their prescriptions until they reached the catastrophic level of coverage.  In 2011 (because of the ACA changes) beneficiaries who reach the coverage gap will only pay 93% of the cost for their generic medications and 50% for their brand name drugs.  Each year this coverage gap will be reduced until it is completely eliminated in 2020. 

“These reductions will significantly lower beneficiary’s out-of-pocket expenses,” says Karen Rozelle, Regional Michigan Medicare/Medicaid Assistance Program (MMAP) Coordinator at the Area Agency on Aging of Western Michigan.  “There still are costs for the Part D Drug plans and when comparing options, individuals need to factor in medications, co-payments, premiums and other out of pocket expenses.”

MMAP is a free program that utilizes trained volunteers to counsel Medicare beneficiaries and their families with Medicare and/or Medicaid questions. They also provide assistance with the Part D drug program process.

This year there are 35 stand-alone prescription drug plans to choose from for Michigan residents. Premiums range from $14.80 to $111.80 each month.  

“Selecting a Medicare Part D prescription drug plan can be an overwhelming process,” says Rozelle. “We encourage seniors to make their health care coverage decisions based on all the facts. Choosing a plan that does not offer the best coverage for their needs can be very costly.”

Once an individual has enrolled in a prescription drug plan, they are under that plan’s guidelines for an entire year, so this is not a choice that should be made lightly.  Rozelle recommends consulting a MMAP counselor, who is trained on what to look for and how to help individuals navigate the Medicare Prescription Drug program.

Medicare beneficiaries must consider all the medications they are currently taking. “Each plan provides different prescription coverage and it is important to include all prescriptions to ensure they are covered under the Part D plan. Not factoring in all of their medications could be a costly mistake,” says Rozelle.

Rozelle recommend reviewing your drug plan each year to see if there have been changes. “It never hurts to be informed,” she states. “Taking precautions to ensure you have the coverage you need may help prevent problems or surprises during the year.”

The ACA also includes coverage for preventative services and some new benefits to Medicare beneficiaries in 2011 like annual free wellness exams. 

MMAP operates statewide so, individuals can call 1-800-803-7174 from anywhere in Michigan and be routed to counselors in their area. Volunteers are available in the nine counties served by the Area Agency on Aging of Western Michigan.

For assistance, or to set up an appointment, call MMAP at 1-800-803-7174.

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Phone: 616-456-5664 or 888-456-5664 • Fax: 616-456-5692

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