Understanding The Medicare Donut Hole

What is the Medicare “Doughnut Hole”? How is the Medicare Part D Doughnut Hole broken down in terms of dollars and cents? How will the Doughnut Hole effect me? If I receive a Low Income Subsidy from Medicare (i.e. extra help) how will the Doughnut Hole affect me? Will I hit the Doughnut Hole? When will I hit the Doughnut Hole? When will the average Medicare enrollee hit the coverage gap called the Doughnut Hole? Do I still have to pay my monthly Medicare Part D premiums while I am in the Doughnut Hole? What expenditures count towards the $2850 level that puts me into the Doughnut Hole? What is the reason that the government created a Doughnut Hole in the Medicare prescription plan? Will the Doughnut Hole be the same in 2015? How many people will hit the Doughnut Hole in 2015? What are out-of-pocket (OOP) expenditures? What expenditures do not count towards my out-of-pocket expenditures? What is the catastrophic coverage point? What other issues are there with the Medicare Part D program that may affect me? How can I avoid the Doughnut Hole?       What is the Medicare “Doughnut Hole”? The Medicare Doughnut Hole is the gap in the 2014 Medicare Plan D coverage between $2850 and $4550 in prescription drug spending. (Please see below for an important note on how your prescription drug spending costs are calculated.) During this gap in coverage, you’ll pay 47.5% of the plan’s cost for covered brand-name prescription drugs and 72% of the price for generic drugs. In 2014, this is a gap in coverage of $1700 that you must... read more

Double dose, Half Cost

Chicagoan Jonathan Winans, 75, is curtailing costs in this time of high gas and food prices, in part, by zeroing in on prescription costs. The retired Dominick’s deli manager has high blood sugar, high cholesterol, arthritis and a heart condition. He’s on a dozen medications, and his wife, Elaine, 76, is on the medication Plaquenil for her arthritis. “I have my doctor write prescriptions for pills at twice the dose and prescribe half a pill,” he said. Then Winans cuts the pills in half with a pill cutter. “Prescriptions last twice as long with just a little more cost,” he said. With the couple only having Medicare Part D prescription drug coverage, costs are a heavy burden, he said. That’s especially true when the “doughnut hole” kicks in for him in the last four or five months of the year, he added. Under Medicare Part D prescription drug coverage, Medicare will pay a percent of drug coverage, minus the deductible, up to a total drug cost of $3,700. After that, seniors have to foot the bill for the costs until they’ve spent $4,950 out-of-pocket and coverage resumes.   The Winans’ other cost-cutting ways: • • “I’ve learned to cut back on gas by ‘stacking’ errands and routing them to put on the least miles,” he said. “I’ll sit down and draw a little map and say, ‘Well, I’ll go to here to here to here.’ I’ll do all [the errands] on a Saturday or a Sunday so that I can get as many trips out of the way as possible with the least amount of mileage.” • • The couple also... read more

Texas Medicare Supplement Options

For those who are soon turning age 65, you are likely to be researching your options for Medicare health care coverage. In doing so, you will find that there are two primary options for obtaining this important health insurance. One option is to go with the Original Medicare. Here, you will be able to receive Medicare Part A and Medicare Part B. With Medicare Part A, various hospitalization services are covered, including certain inpatient procedures. Part B of Medicare covers doctors’ services, as well as some hospital outpatient services, and other miscellaneous care. The other option for receiving Medicare coverage, Medicare Advantage, is also referred to as Medicare Part C. With this Medicare option, you have numerous choices of health care plans. Many of these are set up in a similar manner to an HMO (Health Maintenance Organization) or PPO (Preferred Provider Organization) where enrollees need to choose their providers and health care facilities from a network. The tradeoff, however, is that there are typically many more services that are covered in comparison to Original Medicare, such as dental and vision care. The premiums that are charged for Medicare Part C may also be less. Filling in the Gaps That Medicare Leaves Behind For those who choose Medicare Advantage, there are several items covered about health and wellness. And, while there may be some out-of-pocket charges, these will typically differ from one plan to another. Those who opt for Original Medicare (Medicare Parts A and B), however, will usually run into a fair amount of out-of-pocket costs. This is especially the case if the enrollee encounters many doctor visits... read more

Types of Medicare Advantage Plans

There are several different types of Medicare Advantage plans.   HMO (Health Maintenance Organizations) HMOs account for the largest share (64%) of Medicare Advantage enrollment and have been available under Medicare for several years. HMOs are the most tightly managed plans and utilize a defined network of providers that beneficiaries generally must use to receive care (with some exceptions, such as emergency care).  If you get health care outside the plan’s network, you may have to pay the full cost. Do I need to choose a primary care doctor?  In most cases, yes. Do I have to get a referral to see a specialist?  In most cases, you need a referral.  Certain services, like yearly screening mammograms, don’t require a referral.   PPO (Preferred Provider Organizations) PPOs also utilize provider networks. However, with PPOs, patients can choose to obtain care outside the network for a higher cost-share amount. Do you need to choose a primary care doctor?  No. Do you have to get a referral to see a specialist? No.  If you see a Plan specialists cost will usually be lower.   PFFS (Private Fee-for-Service Plans) PFFS plans are more flexible than HMOs and PPOs because they are not required to establish provider networks. Patients can see “any willing Medicare-approved provider” if the provider accepts the plan’s terms and conditions.  However, some PFFS Plans now have a network. You can also choose an out-of-network doctor, hospital, or other provider, who accepts the plan’s terms, but you may pay more. Do I need to choose a primary care doctor?  No. Do I have to get a referral to see a... read more

The Difference Between MA and MAPD Plans

The Difference Between MA and MAPD Plans     Most (but not all) Medicare Advantage plans include prescription drug coverage. Plans that combine medical coverage AND prescription drug coverage are called Medicare Advantage Prescription Drug (MAPD) plans. It is important to understand the difference between MA-only and MAPD plans.   MA-only plans Replace Original Medicare Administered by private insurance companies approved by Medicare Offer medical coverage only (do not cover prescription medications) Patients can add prescription drug coverage by enrolling in a stand-alone prescription drug plan (PDP) MAPD‏ plans Replace Original Medicare Administered by private insurance companies approved by Medicare Offer combined medical and prescription drug coverage in one comprehensive... read more

2017 Medicare And You Handbook

Welcome to Medicare & You 2017. Since the health care law was passed more than 6 years ago, we’ve seen a transformation in this nation’s health care. We’ve covered 20 million more Americans, while providing higher-quality care at reduced costs. And now, the Quality Payment Program, the result of a bipartisan bill passed last year, builds on these improvements. This program helps make sure Medicare doctors are rewarded for providing improved care to you, instead of being paid based on the number of services they... read more

2016 Medicare Drug Price Comparison Tool

Use Medicare Help’s updated for 2016 Drug Finder Tool. It Helps you find the cheapest prices for all your prescription drugs by comparing all the plan prices for your drugs in your coverage area and provide you with more accurate cost estimates and coverage... read more

5 Tips to Choosing the Best Medicare Plan

With the open registration season for Medicare plans having started on the 15th of October, the time to choose a new 2016 Medicare Advantage or Medicare Part D plan is now. The registration is only open until the 7th of December, so time is most certainly of the essence. To help you make the best healthcare choices possible, here are five tips that will make your experience much easier. 1.) Get to know the MedicareHelp.org’s website Medicare.gov is a powerful tool, and it can help you find the best deals for your particular medical needs. However, it can also be very confusing, with a host of different buttons, options, and menus. Medicare Help’s platform keeps it simple, where you can see all your available plans and your costs on one screen.  And we provide the same information that Medicare.gov offers.  MedicareHelp.org could be useful in your search for the cheapest healthcare. 2.) Know your drugs There are many factors that could affect your payment with regard to your drugs. Their dosages, particular restrictions surrounding them (such as requiring prior authorization or step-up therapy), co-payments (flat payments that could drastically increase the cost of your plan), or a myriad of other factors could all change your plan. Make sure you know everything about your drug(s) before attempting to choose a 2016 Medicare Part D plan. The different combinations of drugs, dosages, pharmacies, regions, and more all affect the cost outcome. Finding the right 2016 Medicare Advantage or Part D plan for you personal health combination accurately could save you hundreds of dollars. 3.) Look at the quality ratings Each plan has a unique rating,... read more

2016 Medicare and You

We’re excited that 2015 marked the 50th anniversary of President Lyndon B. Johnson signing into law the Medicare program. Medicare has been protecting the health and well-being of American families and saving lives for five decades. Over the years, Medicare has grown and today provides quality health coverage for more than 50 million Americans. But we’re not stopping there. Every day, we’re working to make Medicare even stronger to offer you better care and to keep you healthy. Having Medicare provides peace of mind, but it’s also important that you’re getting the most out of your coverage. Use this handbook as a resource to help... read more

2016 Plan Directory

This directory contains information for Medicare Advantage, demonstration, PACE, and cost organizations that have an active contract with CMS at the time of the directory’s publication. These data have been extracted from the Health Plan Management System (HPMS), maintained by the Center for Drug and Health Plan Choice/Medicare Drug Benefit and C & D Data Group/Division of Plan Data (CPC/MDBG/DPD). This directory will be updated on a monthly basis. The plan directory contact data is maintained by each organization in HPMS. If an organization needs to update its contact data, the plan user should use the following navigation path in HPMS: HPMS Homepage > Contract Management > Contract Management > Select a Contract Number > Contact Data > Plan Directory Contact for Public Website. The enrollment number displayed in this directory has been pulled from the “Monthly Enrollment by Contract” file posted on the CMS public website. This enrollment number represents the number of enrollees for which the contract received payment for the month. As asterisk in place of the enrollment number indicates that the count is less than 10. Pilot contracts are excluded from this... read more

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