Aa
Tell about the "Medicare donut hole"
Regarding Quixotic1's mention of: "For people who don't understand the Medicare donut hole I will discuss it, if asked."
Being on Medicare, I'm interested in what this is.
Being on Medicare, I'm interested in what this is.
Don't forget that Baucus isn't the end-all-be-all on health insurance reform. He's been trying to come up with a plan that both Republicans and Democrats will agree on, but it seems to involve leaving all the stuff in that really hurts the lower-income people.
They shot down closing the doughnut hole in Baucus's committee on Thursday. I have been watching CSPAN
In a major victory for the pharmaceutical industry, the Senate Finance Committee on Thursday shot down legislation to provide seniors full coverage through the controversial coverage gap in Medicare’s prescription drug benefit.
The proposal, sponsored by Sen. Bill Nelson (D-Fla.), would have closed Medicare’s so-called “doughnut hole,” which forces millions of seniors each year to pay full prescription costs after annual expenses have reached a certain threshold. The Congressional Budget Office estimated this week that the proposal would save the government $106 billion over 10 years — enough to close the gap in coverage under Part D with $50 billion left over, according to Nelson.
Alex
In a major victory for the pharmaceutical industry, the Senate Finance Committee on Thursday shot down legislation to provide seniors full coverage through the controversial coverage gap in Medicare’s prescription drug benefit.
The proposal, sponsored by Sen. Bill Nelson (D-Fla.), would have closed Medicare’s so-called “doughnut hole,” which forces millions of seniors each year to pay full prescription costs after annual expenses have reached a certain threshold. The Congressional Budget Office estimated this week that the proposal would save the government $106 billion over 10 years — enough to close the gap in coverage under Part D with $50 billion left over, according to Nelson.
Alex
Here is my experience with the donut hole.
The first phase is where I pay a copay for my meds, generally $10 for generics and $30 for brand name. My Medicare plan picks up the rest. This goes on until the combined, total cost to me and my insurer reaches about $2500. The thing to note is that this point is the "combined" cost to both (ie. the total cost of the med). "Special meds" require a 30% copay. More about this later.
At about $2500 one reaches the "donut hole". Then the rules change. This is where it gets confusing and the rules change. Now, the only thing that is counted is what comes out of the patient's own pocket FROM THE VERY BEGINNING OF THE YEAR. Typically when this point is reached the patient only has spent a few hundred dollars. The donut hole requires that the patient spend $4300 out of pocket before the insurer has to pay another dime. For the average person this will be most of the rest of the year unless they have very expensive meds. What a rip-off! Only people who are on cheap brand names will avoid entering the hole.
At $4300 the "Catastrophic" Coverage begins. The patient now has to pay only a few dollars for any med in the formulary and 20% of any special meds. Life gets easy again.
So, the creators of this plan use one situation to reach the hole (payments by insurer and by patient) so that the hole is reached very quickly. The second point at the end of the whole is reached by counting ONLY the money spent out of pocket from the beginning by the patient.
In my case, the DMD costs about $1700. From the beginning I have to pay 30% of its cost because it is a special med.
First month, I have a $250 deductible, then I have to pay 30% of my DMD which is about $570, so my outgo is $790. The amount counting toward the first endpoint is $1700.
The second month I reach the first endpoint and enter the donut hole because the combined cost is now $3400. I pay 30% of the amount between the $1700 we have already reached and the beginning of the donut hole. This is $800 and I pay about $268. Then I am responsible for ALL of the amount that exceeds the first donut hole point of $2500. So I pay the remaining $900 also.
My second month my responsibility is $1168.
Now the "new counting" takes over. I have spent $1958 out of pocket for the year, and we have just finished the second month.
The third month the cost of my DMD is still $1700. I have to pay all of it. Now my out of pocket expenses have reached $3658. I am still in the donut hole. (Remember we are counting only MY out of pocket costs for the year).
The fourth month the DMD is $1700. To finish my time in the donut hole I have to pay the final amount to reach the $ endpoint of $4300. So I pay $658 and a little copay for the remainder.
Then, I am on Catastrophic coverage and the insurer picks up all of my regular meds for a tiny copay, but I still have to pay 10% of the "special meds" cost so I have to pay $170 for my DMD. The $170 is monthly to the end of the year. Then it all starts over again.
I know this sounds incredibly complex. I believe that they made it this way so that most people wouldn't understand it and howl when they got it passed.
When you add in the other expensive meds I am on, like Provigil, you can see how I reach the donut hole by the end of the second month and am out of it by the end of the third month. Every year I have to come up with $4300 within the first 2 months. I don't have that kind of discretionary money. There is no way to spread it out. I also make too much to qualify for the vast majority of aid programs. Also, there are huge restrictions on Medicare, so that we cannot benefit from ANY discounts, or free meds, or bonus points from our prescriptions. Like some pharmacies will give you a gift card for the store if you transfer a prescription - NOT if if is a Medicare prescription.
Alex - you are correct that we need to be vocal about making the donut hole more humane or eliminating it all together. And we DO need to eliminate the 2 year waiting period before Medicare kicks in. It is during this "waiting period" that so amny people go bankrupt from medical expenses.
Nancy - If you are diagnosed with MS and not on a DMD, then your Neuro is not following the standard of care in his field. All people with a diagnosis should be offered a DMD and most people with a clear CIS (Clinically Isolated Syndrome) should be on one. RRMS responds better to the DMDs the earlier it is taken in the disease course. This is a scientific fact. If they are withholding a DMD because you are on Medicare, then you are receiving second-class care because of your age and your civil rights are being violated.
The Helath Care Overhaul being contemplated does have a softening of the Medicare Donut Hole restrictions, at least it did a couple months ago. I have been too buried in construction to follow it.
Quix
The first phase is where I pay a copay for my meds, generally $10 for generics and $30 for brand name. My Medicare plan picks up the rest. This goes on until the combined, total cost to me and my insurer reaches about $2500. The thing to note is that this point is the "combined" cost to both (ie. the total cost of the med). "Special meds" require a 30% copay. More about this later.
At about $2500 one reaches the "donut hole". Then the rules change. This is where it gets confusing and the rules change. Now, the only thing that is counted is what comes out of the patient's own pocket FROM THE VERY BEGINNING OF THE YEAR. Typically when this point is reached the patient only has spent a few hundred dollars. The donut hole requires that the patient spend $4300 out of pocket before the insurer has to pay another dime. For the average person this will be most of the rest of the year unless they have very expensive meds. What a rip-off! Only people who are on cheap brand names will avoid entering the hole.
At $4300 the "Catastrophic" Coverage begins. The patient now has to pay only a few dollars for any med in the formulary and 20% of any special meds. Life gets easy again.
So, the creators of this plan use one situation to reach the hole (payments by insurer and by patient) so that the hole is reached very quickly. The second point at the end of the whole is reached by counting ONLY the money spent out of pocket from the beginning by the patient.
In my case, the DMD costs about $1700. From the beginning I have to pay 30% of its cost because it is a special med.
First month, I have a $250 deductible, then I have to pay 30% of my DMD which is about $570, so my outgo is $790. The amount counting toward the first endpoint is $1700.
The second month I reach the first endpoint and enter the donut hole because the combined cost is now $3400. I pay 30% of the amount between the $1700 we have already reached and the beginning of the donut hole. This is $800 and I pay about $268. Then I am responsible for ALL of the amount that exceeds the first donut hole point of $2500. So I pay the remaining $900 also.
My second month my responsibility is $1168.
Now the "new counting" takes over. I have spent $1958 out of pocket for the year, and we have just finished the second month.
The third month the cost of my DMD is still $1700. I have to pay all of it. Now my out of pocket expenses have reached $3658. I am still in the donut hole. (Remember we are counting only MY out of pocket costs for the year).
The fourth month the DMD is $1700. To finish my time in the donut hole I have to pay the final amount to reach the $ endpoint of $4300. So I pay $658 and a little copay for the remainder.
Then, I am on Catastrophic coverage and the insurer picks up all of my regular meds for a tiny copay, but I still have to pay 10% of the "special meds" cost so I have to pay $170 for my DMD. The $170 is monthly to the end of the year. Then it all starts over again.
I know this sounds incredibly complex. I believe that they made it this way so that most people wouldn't understand it and howl when they got it passed.
When you add in the other expensive meds I am on, like Provigil, you can see how I reach the donut hole by the end of the second month and am out of it by the end of the third month. Every year I have to come up with $4300 within the first 2 months. I don't have that kind of discretionary money. There is no way to spread it out. I also make too much to qualify for the vast majority of aid programs. Also, there are huge restrictions on Medicare, so that we cannot benefit from ANY discounts, or free meds, or bonus points from our prescriptions. Like some pharmacies will give you a gift card for the store if you transfer a prescription - NOT if if is a Medicare prescription.
Alex - you are correct that we need to be vocal about making the donut hole more humane or eliminating it all together. And we DO need to eliminate the 2 year waiting period before Medicare kicks in. It is during this "waiting period" that so amny people go bankrupt from medical expenses.
Nancy - If you are diagnosed with MS and not on a DMD, then your Neuro is not following the standard of care in his field. All people with a diagnosis should be offered a DMD and most people with a clear CIS (Clinically Isolated Syndrome) should be on one. RRMS responds better to the DMDs the earlier it is taken in the disease course. This is a scientific fact. If they are withholding a DMD because you are on Medicare, then you are receiving second-class care because of your age and your civil rights are being violated.
The Helath Care Overhaul being contemplated does have a softening of the Medicare Donut Hole restrictions, at least it did a couple months ago. I have been too buried in construction to follow it.
Quix
Medicare is my primary insurance with Health New England as secondary. I can't call up a list of the formulary prescription drugs online and they're not listed in the HNE handbook - would have to place a telephone call to find out if something in particular is covered.
About five months ago, the neurologist (& 2nd opinion, but not the 3rd opinion) thought I should be on daily meds - Copaxone. At last visit, in July, this was not mentioned again - probably on the basis of the 3rd opinion, which was to have yearly brain MRI and watch - so, I guess that's what is happening at this time.
My concern is if I do have to go on Copaxone, whether or not it is listed as a covered Rx with HNE (which pays for my prescriptions) - and what the cost to me would be.
About five months ago, the neurologist (& 2nd opinion, but not the 3rd opinion) thought I should be on daily meds - Copaxone. At last visit, in July, this was not mentioned again - probably on the basis of the 3rd opinion, which was to have yearly brain MRI and watch - so, I guess that's what is happening at this time.
My concern is if I do have to go on Copaxone, whether or not it is listed as a covered Rx with HNE (which pays for my prescriptions) - and what the cost to me would be.
This is one of the points we need to be vocal about eliminating as well as the two year mandatory wait for medicaid. The reason the donut hole was put in was Congress does not negotiate drug prices for medicare.
Alex
Alex
Everyone on Medicare is eligible to participate in its prescription drug insurance program, generally known as Medicare Part D. A large number of insurance providers offer Part D coverage.
No matter which the insurer, though, the law specifies that only a certain dollar amount in prescription drugs is covered for a given (calendar?) year. After that, the insured person falls into the 'donut hole' and must pay out of pocket until he/she reaches another set point, after which the insurance plan kicks in again, without limits this time, I believe.
I don't know what the dollar amounts are, since I don't have Part D coverage. But it adds up really fast for MSers on one of the DMDs. Very early in a given year the donut hole is reached. Then there could be a few months where the DMD must be paid for entirely by the patient. This of course is a hardship for nearly everyone.
My prescription plan does not include a donut hole provision, and is certified as being 'at least as good as' Part D coverage. That means that if for some reason I'd ever want to switch into it, I will not be penalized for the delay.
I advise anyone here who is eligible for Medicare because of either age or disibility status to look into all options carefully.
ess
No matter which the insurer, though, the law specifies that only a certain dollar amount in prescription drugs is covered for a given (calendar?) year. After that, the insured person falls into the 'donut hole' and must pay out of pocket until he/she reaches another set point, after which the insurance plan kicks in again, without limits this time, I believe.
I don't know what the dollar amounts are, since I don't have Part D coverage. But it adds up really fast for MSers on one of the DMDs. Very early in a given year the donut hole is reached. Then there could be a few months where the DMD must be paid for entirely by the patient. This of course is a hardship for nearly everyone.
My prescription plan does not include a donut hole provision, and is certified as being 'at least as good as' Part D coverage. That means that if for some reason I'd ever want to switch into it, I will not be penalized for the delay.
I advise anyone here who is eligible for Medicare because of either age or disibility status to look into all options carefully.
ess
Just remember that if your only income is your disability check then you could possible be eligible for medicaid or the medicare advantage program. If you do qualify for either one of these then you would no longer have a doughnut hole to worry about...
I'll be praying,
Carol
I'll be praying,
Carol
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