Medicare 2019 Changes
New (DIS)Enrollment Period
The Medicare Advantage Disenrollment period lets you drop your Medicare Advantage plan and return to Original Medicare (Part A and B). It also lets you sign up for a stand alone drug plan.
Coverage Gap (Donut hole)
The Coverage Gap or Donut Hole (or Doughnut Hole) has caused a considerable amount of confusion for many people when they suddenly are required to pay a higher price (or before 2011, the full price) for their prescription medications. The following brief overview is based on the 2018 Medicare Standard Benefit Plan Model.
- According to the Centers for Medicare and Medicaid Services (CMS) the Standard Medicare Part D Prescription Drug Plan, the Donut Hole phase of your Medicare Part D coverage begins when your total retail drug costs reach $3750. (In past coverage years, some Medicare Part D plans have implemented a different Initial Coverage Limit and have begun the Donut Hole phase a little earlier – perhaps at a total retail drug spending of $1800.)
- Please note, this $3750 is the total retail cost of the covered medications, not what you spend personally at the pharmacy. As a Medicare Part D beneficiary, you will pay only a portion of the $3750 and your Part D plan pays a portion. Your total retail cost of prescription medications is calculated from your Medicare Part D plan’s negotiated retail drug price – and every Medicare Part D plan can have a different negotiated retail drug price. So it is possible that you may reach the Donut Hole a little earlier or later than someone else who uses the exact same prescription medications, but this other person has enrolled in a prescription drug plan from another Medicare Part D plan provider.
- As a note, in the CMS model Medicare Part D plan, a beneficiary; like yourself, pays the first $405 dollars as an initial deductible and then is responsible for paying 25% of the next $3345, for a total out of pocket medication costs (or true out-of-pocket costs -— TrOOP) of $1241.25 (excluding your monthly plan premiums).
- Again, following the CMS standard model Medicare Part D plan, when you reach the Donut Hole, your Medicare Part D plan will have paid the difference between the negotiated retail cost of all your drug purchases and your out of pocket cost or $2508.75.
- However, most people simply say that you enter the Donut Hole phase of your Medicare Part D plan at the end of your Initial Coverage phase or when your reach your Medicare Part D plan’s Initial Coverage Limit (again, around $3750).
- With changes in the Medicare law, a $250 Donut Hole Rebate program was implemented in 2010. Anyone who reached the 2010 Donut Hole was automatically mailed a check for $250. Click here to read some frequently asked questions about the 2010 Donut Hole rebate.
- The 2011 Donut Hole marked the beginning of an effort at closing the Donut Hole. In 2011, anyone reaching the Donut Hole received a 50% discount on brand-name formulary drugs and a 7% discount on all generic formulary medications.
- In 2018, anyone reaching the Donut Hole will receive a 65% discount on brand-name formulary drugs and a 56% discount on all generic formulary medications. So for your brand-name drug purchases, you will pay only 35% of the retail cost, but receive 85% credit toward meeting your Donut Hole exit point or TrOOP. For generic drug purchases, you pay 44% of the retail cost and receive the same 44% credit toward TrOOP. Click here if you would like to read more about the Donut Hole drug discount program.
- You will stay in the Donut Hole until your TrOOP (True Out-of-Pocket) costs reach $5000
- Plan test drives
- New regulations will let people try an Advantage plan for up to three months and, if they aren’t satisfied, they can switch to another Medicare Advantage plan or choose to enroll in original Medicare. Congress required this flexibility in the 21st Century Cures Act, designed to accelerate innovation in health care.
