This article explains the coverage gaps in Medicare Part B and Part D plans, including the “donut hole.”
What are the primary coverage gaps within Medicare?
Each Medicare plan comes with a deductible which must be met before Medicare begins paying. Part B has a coverage gap of 20% where Medicare only pays 80% for provider services (including factor therapies) once the deductible is met. Part D has a gradient of limited coverage once the deductible is met and until the subscriber enters catastrophic coverage.
What is the Part B coverage gap?
In Part B plans, Medicare covers 80% of costs for providers, including procedures and Part B infusion therapies like factor. To cover these costs, you may be eligible for a Medigap/Supplemental Insurance policy. Depending on your income level and resources, you may also be eligible for assistance through the Qualified Medicare Beneficiary (QMB) program or the Specified Low Income Medicare Beneficiary (SLMB) program.
What is the Part D coverage gap?
Often called the “donut hole,” this is a euphemism to describe a coverage gap where, after Medicare has paid a portion of shared costs, Medicare temporarily limits its coverage. During that stage of coverage, you may pay more for drugs than you had previously. When the coverage gap (donut hole) ends, Medicare will require a flat 5% shared cost on prescription drugs.
In Part D, you will first pay the deductible, $480. At that point, Medicare will begin sharing the cost based on their drug tier cost-sharing formula. Medicare will share the cost until $4660 has been reached, and the donut hole begins. From there, you will pay 25% of the drug cost until the shared cost reaches $7400. At that point, you are in “catastrophic coverage”, and Medicare will pay 95% of drug costs; you will be responsible for 5% for the rest of the year.
What can BioMatrix do to help with the coverage gaps in Part B and Part D?
BioMatrix can check your Medicare benefits and let you know what your anticipated costs will be based on your plan choices. From there we can provide additional information based upon your needs. By looking at your income and resources, we can identify support plans you may be eligible for.
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