Medicare Part D: What Do You Get?
What is Medicare Part D?
Medicare Part D is a Medicare program designed to finance the costs of prescription drug. It was introduced in 2003, as part of the Medicare Modernization Act and was officially available to the public in 2006.
Medicare Part D encompasses a variety of drug plans—each of which covers its own formulary of drugs. The list of drugs that a plan covers is called a formulary. The cost of drug plans varies based on which types of drugs you need and whether you participate in your plan’s network of pharmacy. There is also no standard monthly premium for Part D, as it depends on the drug plan, which sets premiums every year. Important fact: Medicare has a master formulary, but each company is allowed to have its own formulary based on Medicare’s formulary. Although company formulary’s must have drugs available in every health category, they do not have to be the same drugs. So make sure you know your particular medications are covered by the plan you choose.
How Does Medicare Part D Work?
Medicare Part D is offered through dozens of plans but there is a standard. The standard benefit is the minimum enacted by the law. Here is the breakdown of the most basic model for Medicare Part D costs in 2017:
Part 1: $400 Deductible 2017
The initial fee; it may be covered by some plans that provide “first dollar coverage”
Part 2: Coverage
The beneficiary has a co-insurance or a medication co-payment.
Part 3: The Coverage Gap or Donut Hole
The beneficiary pays all medication costs in this gap. There are some plans that pay for this gap. (You pay 45% of the full cost, but they count dollars spent at 100% of retail). Starts at $3700 in 2017.
Part 4: Catastrophic Coverage
This coverage comes into effect when a beneficiary has spent over $4,950 for prescription drugs. It greatly reduces the cost of such medications.
Medicare Part D Eligibility
The most suitable beneficiaries to enroll in Part D do not have any sort of drug coverage, e.g. Employer coverage. To be eligible for Part D, you must be eligible to be insured by Medicare. To receive Part D coverage, you must enroll in a Part D plan. To enroll in a Part D plan, you must be eligible for Medicare Part A or B, though you do not need to be currently enrolled in either of these plans to qualify for Part D. The people who are enrolled in Medicaid will be enrolled in Medicare Part D by the government through the Medicare Savings program. Medicaid recipients still choose their plan, but the government pays the premium and significantly reduces their cost.
Enrolling in Medicare Part D
To enroll in Medicare Part D, you must choose a Part D plan that works best for your needs. This is done by directly signing up at the Official Medicare website: https://www.medicare.gov/. From there you select the icon that reads “Find health & drug plan.” You will be asked basic prescription and location information when in the Drug Plan Finder. Once you find the drug plans for your needs, you are free to enroll online or by calling the number shown to connect with a Part D enrollment specialist.
It is best to enroll in a plan when you are first eligible for it, otherwise, you will be hit with a penalty. Medicare has a 1% increase in the premium cost with every month you hold off enrollment. The period in which you are first eligible to enroll in Part D is known as the Initial Enrollment Period or IEP. If you do not enroll in a Part D plan during the IEP, you might not be able to join again until Fall Open Enrollment, which is from October 15-December 7.
Enrollment lasts for 7 months, which includes the 3 months before the month you officially became eligible for Medicare, the month of your eligibility and the 3 months following the month you became eligible.
Example: If your eligibility month is in June (because you turn 65 then), your IEP will run from March 1 to September 30 of that year.
How You’ll Receive Coverage by Enrollment Period:
Anytime before your Medicare starts you will start on the first day of Medicare.
The month of Medicare start or the 3 months after, you will begin Part D the 1st of the next month.
Medicare Part D Plans
There are various Part D plans available through private insurance companies that Medicare approves. Drug plans differ by region and your prescription drug needs. There are two types of coverage:
- PDP– This is a stand-alone plan that provides drug coverage only. It is used by beneficiaries of health benefits that come from the traditional Medicare-fee-for-service program. It can be used with Medicare Supplement.
- Medicare Advantage Plan– This plan subsidizes both drugs and medical services. It is used by beneficiaries who receive their Medicare benefits in a single package. This is done through a health maintenance organization (HMO) or a preferred provider organization, or PPO.
Every type of plan includes the following payments: deductibles, premiums, co-pays and co-insurance. The costs of the plans differ, as do the specific prescription drugs they cover. Checking each plan’s formulary will help you avoid choosing a plan that doesn’t cover the drugs you need.
Medicare Part D Donut Hole
The Part D donut hole is the coverage gap that strongly affects out-of-pocket prescription drug costs. The donut hole puts a restriction on how much your Part D plan will pay for covered drugs. Beneficiaries in the donut hole pay higher percentages for both brand name and generic drugs. Unfortunately, most Medicare Part D plans have these coverage gaps.
Not everyone enters the coverage gap and it depends on a variety of factors including cost-sharing expenses, type of drugs, drug costs and how much your plan pays for covered drugs. There is a greater risk of entering the donut hole for people with more expensive drugs, high co-payments or co-insurance costs.
There are healthcare reforms such as government subsidies and manufacturer discounts that will offset the prices of a covered generic or brand-name medication. If you enter the donut hole, you automatically receive catastrophic coverage when your out-of-pocket spending reaches a certain limit.
Medicare Part D Timeline
2003- Congress passes the Medicare Prescription Drug, Improvement, and Modernization Act. Only inpatient hospital drugs are covered.
2006- Medicare launches Part D coverage for Medicare beneficiaries. It pays for outpatient prescription drugs.
2007- Medicare recipients have an average of 56 plan options, the peak of Part D plans.
2010- The Affordable Care Act enforced provisions to gradually close the donut hole.
2011- Most Part D Plans, 80% specifically, prefer pharmacies where retirees pay lower cost sharing on drugs.
2015- The number of Medicare beneficiaries tips the scale at 55, 504,005 people. The average monthly premium rose from $25.93 in 2006 to $37.02.
2020- The donut hole will be closed for good.