“What’s The Donut Hole?”

hero_donuthole_320_dd

On January 1, 2006, the US federal government introduced a program to subsidize the costs of prescription drugs and prescription drug insurance premiums for Medicare beneficiaries.  You must enroll in a Part C (Medicare Advantage with Drug) or Part D (Stand Alone Prescription Drug) plan to participate in this federal-government-subsidized drug program.

Here’s a summary on how these plans work.

In 2017, Part C and Part D plans often require you to first pay a defined deductible, then use tiered drug co-payments from you up to an initial coverage limit of $3700 – which is the full retail cost of prescriptions. Once this $3700 initial coverage limit is reached, you will have to pay a larger cost share of your prescription drugs up until your total out-of-pocket expenses (deductible and copay expense excluding) reaches $4,950 infamously referred to as the “Donut Hole”.

donut-hole

Let’s review the Four Stages:

screen-shot-12-07-16-at-06-37-pm

Stage 1: Deductible, if applicable

Similar to many auto and home insurance plans, some Part C (Medicare Advantage with Drug) or Part D (Stand Alone Prescription Drug) plans include an annual deductible where you pay the total cost of drugs until you reach the deductible amount.   Some plans set the deductible only for brand name drugs; check for your plan specifics. (Deductible payments are included in the amount counted toward the $4950 Maximum Out of Pocket level for 2017.)

Stage 2: Initial Coverage Up to $3,700 in Total Cost

In this stage you share cost with your Part C (Medicare Advantage with Drug) or Part D (Stand Alone Prescription Drug) plan, usually as fixed amount copays or percentage co-insurance.  The plan pays for the rest until the Total Drug Costs paid by the plan and you (including the Stage 1 Deductible) reach $3,700.

img_20151208_095456.jpg

In this example, the copay was $3.00 and the plan paid $374.31. Added together, the total $377.31 would count toward the $3,700.  After ten refills, the total $3,773.10 combined paid by the plan and member would exceed the $3,700 Stage 2 Initial Coverage.  The beneficiary member would then have exhausted the plan’s Initial Coverage and incur higher cost sharing in Stage 3, the Coverage Gap or “Donut Hole”

Stage 3: Coverage Gap or “Donut Hole” 

This is when my phone rings.  The conversation goes like this:

Client: “Dan, my prescription refill usually costs $X and today I was told the copay was double or triple that amount.”

Me: “Have you been receiving reports from the plan showing how the total cost of your prescriptions, what you and the plan paid together, has been creeping closer to that $3,700 threshold?”

Client:  “Yes.  But this is a shock.”

Yes, having exhausted the $3,700 in Stage 2 Initial Coverage, you now incur greater cost sharing.  In 2017, when you reach this stage you will be responsible for 40% of the cost of brand name drugs, 51% of generic drugs.  Then, once your year-to-date deductible, copay and coinsurance costs (Stages 1-3) reach $4,950 you then move to Stage 4.

Stage 4: Catastrophic Coverage after your out of pocket reaches $4,950

After the Stage 1, Stage 2 and Stage 3 combined Out of Pocket deductible, copay and coinsurance costs reach $4,950, you pay very little and your Part C (Medicare Advantage with Drug) or Part D (Stand Alone Prescription Drug) plan pays about 95% of the cost until the end of the year.   Then, on January 1, new plan begins again in Stage 1.

suggestions

Below are a few suggestions on how to delay the day by which you enter the “Donut Hole” Coverage Gap and stretch your copay dollars all year long.

  1. Preferred Pharmacy.  If you are in a Part C (Medicare Advantage with Drug) or Part D (Stand Alone Prescription Drug) make sure you fill your prescriptions at a preferred pharmacy where you can save on total costs compared with other drug-stores in your network.  Call your health plan for preferred stores near you.
  2. Generics.  According to AARP, the FDA will approve around 500 new generics next year.  Each will have the same active ingredient, quality, safety and strength as its branded original. Ask your doctor or pharmacist if the brand name drug you’re taking may have a generic option.
  3. Discounts.  Many larger retailers and supermarkets offer deep discount prices for popular generics.  Ask for copies of the chain’s discount list of generics to show to your doctor before he or she writes your prescriptions.  .
    • Example> Hannaford Price Chopper Walgreens
    • Check out GoodRx, a drug-price comparison web site.
    • (Also ask if the chain will fulfill the order independent of your Medicare Part D plan so the cost of the drug isn’t counted toward the $3,700 Initial Coverage.)
  4. Manufacturer.  If you need an expensive specialty drug and the Medicare plan doesn’t cover it, call the drugmaker. Many have customer assitance teams ready to assist families with household incomes up to $100,000.
  5. State Pharmacy Assistance Programs
  6. Social Security Extra Help offers subsidizes Prescription Drug Plan Costs to beneficiaries with limited income and limited resources.  [brochure]

helpNeed Help?  Please call me at (518) 346-2115 or send a quick note with your contact information and question.

 

When what we do helps someone…

…. it’s great to hear results.

Just before Thanksgiving I met with a recently widowed woman.  Still in mourning, she was reeling from her loss and struggling to make sense of her health plan costs and her dramatically reduced monthly income.

When she disclosed her assets and monthly income, I explained to her some programs she was likely eligible for and provided assistance with the enrollment process.

For starters, the easy one. I enrolled this client in the New York State Elderly Pharmaceutical Insurance Coverage (EPIC) program. EPIC helps with Medicare Part D premiums, prescriptions co-pays and the Part D “donut hole.”

Then, we confirmed she was eligible for Social Security Extra Help – available to Medicare participants with limited resources.

Third, New York State offers Part B premium assistance to Medicare participants with limited income and resources.

I love what I do.

When I received this note with the closing “Thank you again for giving me my life back” it reminds me of why we serve – to add some value to another’s life.  This is fulfilling and rewarding in its own way.

2016 0215 Thank you note

http://www.myuhcagent.com/daniel.alcorn
(518) 346-2115

New York EPIC and Medicare Part D

epic1 epic2

2016 EPIC CoPayment

 

The Elderly Pharmaceutical Insurance Coverage (EPIC) program is a New York State Program that provides seniors with co-payment assistance for Medicare Part D prescription drugs.

  • Members must be enrolled in a Medicare Part D drug plan. including any Medicare Advantage plan with Part D prescription drug coverage
  • Provides secondary coverage for Medicare Part D and EPIC covered drugs purchased after the Part D deductible, if any, is met.

Who Is Eligible to Enroll?

  • You must be a resident of New York State with annual income up to $75,000 if single or $100,000 if married.  (Based on most recent NY State tax filing Adjusted Gross Income, Plus Social Security Benefits Less Part B premiums)
  • You must be age 65 or older and not receiving full Medicaid benefits.
  • You must be enrolled in a Medicare Part D plan; either standalone or combined within a Medicare Advantage plan.

What Does EPIC Cost?
EPIC has two plans based on your income.

  • The Fee Plan is for members with income up to $20,000 if single or $26,000 if married. Benefits begin immediately.
  • The Deductible Plan is for members with incomes ranging from $20,001 to $75,000 if single or $26,001 to $100,000 if married. Benefits begin when the deductible (Part D co-payment) has been met.

What Are The Benefits?

  • EPIC provides secondary coverage for Medicare Part D covered drugs purchased after the Part D deductible, if any, is met.
  • EPIC co-payments are $3, $7, $15 or $20 based on the prescription cost after your Part D (see below)
  • Up to $41 monthly Part D drug plan premium assistance is available for members with annual income below $23,000 if single or $29,000 if married. (This monthly amount is adjusted yearly)
  • EPIC members enjoy a once annual special election period to enroll or change their Medicare Part D prescription drug plan, including any Medicare Advantage plan with Part D prescription drug coverage.

 

Next Step

  • Confirm you meet the above residency, age and income eligibility requirements.
  • Download, print, complete and mail in the EPIC application.  Download the PDF EPIC Application Here
  • You will receive a separate EPIC Member card.  Provide the EPIC Member ID number to your New York based retail and mail order pharmacy.
  • New York based retail and mail order pharmacies are connected to EPIC and will report your out of pocket copay. Do this even if you’re income has you in the deductible plan in case your drug needs change later in the year.
  • Once the EPIC fee based or deductible plan requirement is met, EPIC steps  in as secondary coverage which reduces your copay to  $3, $7, $15 or $20 (see below)

red_arrow

For Existing EPIC Members – Annual Renewal Process

  • You do NOT have to reapply for EPIC each year.
  • EPIC reviews your residency and income on an annual basis to confirm eligibility and updated Fee or Deductible levels.
  • At Year One, EPIC will obtain updated residency and income information from government tax files and advise you in writing of any fee or deductible change.
  • At Year Two and every two years, EPIC will send you a form to update your contact information, address and income and advise you in writing of any fee or deductible change.
  • EPIC Member Service telephone number is 800-332-3742 (Monday through Friday until 5:00 pm / eastern)

And, of course, if you have any questions about your Part D prescription drug coverage please don’t hesitate to call me at (518) 346-2115.

Read more of this post

Family Caregivers Kit: 9 Free Publications

helpManage a loved one’s finances and health care with knowledge and confidence.

The Family Caregivers Kit is a collection of publications that help you understand your duties as an agent under a power of attorney, keep track of medications, protect your loved ones from scams, and more.

 

PUBLICATIONS FEATURED IN THE FREE FAMILY CAREGIVERS KIT

( Download Adobe Reader to view these publications.)
  1. Consumer Action Handbook  Family Caregivers Kit -1
  2. Health Scams Family Caregivers Kit -2
  3. Money Smart for Older Adults: Financial Exploitation  Family Caregivers Kit -3
  4. Managing Someone Else’s Money: Fiduciary   Family Caregivers Kit -4
  5. Managing Someone Else’s Money: Court Appointed Guardians Family Caregivers Kit -5
  6. Managing Someone Else’s Money: Representative / VA Fiduciary Family Caregivers Kit -6
  7. Managing Someone Else’s Money: Trustees / Revocable Living Trust Family Caregivers Kit -7
  8. My Medicines  Family Caregivers Kit -8
  9. Use Medicines Wisely  Family Caregivers Kit -9

 As an independent licensed Life, Accident and Health Insurance professional, I represent several insurance companies authorized to conduct business in New York.  For more information about how affordable insurance can protect your assets and provide you greater control over your financial planning, please contact me at (518) 346-2115 for a confidential and complimentary consultation.

"This service is provided by the Consumer Financial Protection Bureau, 
Food and Drug Administration's Office of Women's Health and the 
Federal Citizen Information Center at the General Services Administration."

NY State EPIC Drug Plan for Seniors

drug-costsEPIC, (Elderly Pharmaceutical Insurance Coverage) is a New York State program for seniors administered by the Department of Health. It helps eligible seniors supplement their out-of-pocket Medicare Part D drug plan costs.  Eligibility requirements are:

  • Resident of New York State
  • Age 65 or older
  • Income up to $75,000 (single) or $100,000 if married.

EPIC offers two plans, based on your income:

  • Fee Plan for members with income up to $20,000 if single or $26,000 if married.
  • Deductible Plan members with incomes ranging from $20,001 to $75,000 (single) or $26,001 to 100,000 (married.)   Download EPIC Application Here

EPIC members are required to be enrolled in a Medicare Part D drug plan or a Medicare Advantage health plan which includes Part D. Enrolling in EPIC will give a member a Special Enrollment Period (SEP) to join a Medicare Part D drug plan. Medicare Part D provides primary drug coverage for EPIC members. After a Part D deductible is met, if applicable, EPIC provides secondary coverage for approved Part D and EPIC covered drugs. EPIC also covers approved Part D-excluded drugs such as prescription vitamins as well as cough and cold preparations after enrolling in a Part D drug plan.

help

You or someone you know may now be eligible for EPIC help.  Download the EPIC Application and call me at (518) 346-2115 for assistance with submitting your request.

 

NY State Budget and Senior Drug Plan expansion

The Elderly Pharmaceutical Insurance Coverage (EPIC) program is a New York State program for seniors administered by the Department of Health. It helps income-eligible seniors aged 65 and older to supplement their out-of-pocket Medicare Part D drug plan costs.

The New York State 2014-15 budget included the expansion of the program to cover the prescription needs of more seniors.  Currently, the eligibility requirements for EPIC are capped at $35,000 for an individual and $50,000 for a married couple. These threshold will rise to $75,00 for an individual and $100,000 for married enrollees.

help

With these new thresholds you or someone you know may now be eligible for EPIC help.  Until the Department of Health prints new forms,  Download the EPIC Application and call me at (518) 346-2115 for assistance with submitting your request.