Medicare Part D coverage gap

In 2006, the first year of operation for Medicare Part D, the doughnut hole in the defined standard benefit covered a range in true out-of-pocket expenses (TrOOP) costs from $750 to $3,600. (The first $750 of TrOOP comes from a $250 deductible phase, and $500 in the initial coverage limit, in which the Centers for Medicare and Medicaid Services (CMS) covers 75 percent of the next $2,000.) In the first year of operation, there was a substantial reduction in out-of-pocket costs and a moderate increase in medication utilization among Medicare beneficiaries, although there was no evidence of improvement in emergency department use, hospitalizations, or preference-based health utility for those eligible for Part D.[2]

The dollar limits increase yearly.

The following table shows the Medicare benefit breakdown (including the doughnut hole) for 2019.

The costs shown in the table above represent the 2019 defined standard Medicare Part D prescription drug plan parameters released by the Centers for Medicare and Medicaid Services (CMS) in April 2017.[3] Individual Medicare Part D plans may choose to offer more generous benefits but must meet the minimum standards established by the defined standard benefit.[4]

The 2019 Medicare Part D standard benefit includes a deductible of $415 (amount beneficiaries pay out of pocket before insurance benefits kick in) and 25% co-insurance, up to $3,820. Once the total annual amount (i.e., amounts paid by both beneficiary and Plan) spent on drugs exceeds $3,820, the beneficiary reaches Part D's coverage gap, also known as "the doughnut hole." During the doughnut hole stage, beneficiaries pay a larger percentage (in 2019, 37% for generic and 25% for brand-name) until the beneficiary's total out-of-pocket spending reaches $5,100. The catastrophic stage is reached after $5,100 of out of pocket spending, then beneficiaries pay either 5% of total drug cost or $3.40 (for generics) and $8.50 (for brand-name drugs).[4]

The Low-Income Subsidy (LIS), also known as "Extra Help" provides additional cost-sharing and premium assistance for eligible low-income Medicare Part D beneficiaries with incomes below 150% the Federal Poverty Level and limited assets. Individuals who qualify for the Low-Income Subsidy (LIS) or who are also enrolled in Medicaid do not have a coverage gap.[5]

To qualify for the LIS, Medicare beneficiaries must qualify for full Medicaid benefits, be enrolled in Medicare Savings Programs (MSP), and receive Supplemental Security Income (SSI). These individuals automatically qualify for the subsidy and do not have to apply separately. Others may qualify after applying through their state Medicaid programs or through the Social Security Administration (SSA) and fulfill income and asset requirements. In a marketplace review conducted by the Kaiser Family Foundation in 2010, only 40% of eligible low-income beneficiaries who did not automatically qualify for the LIS actually received it.[6]

The majority of Medicare beneficiaries who qualify for the LIS will pay no premiums or deductibles and no more than $8.25 for each drug that their plan covers. In addition, beneficiaries with Extra Help are not penalized for late enrollment in a Part D plan. LIS recipients also benefit from a Continuous Special Enrollment Period to join or switch plans during any time of the year. They do not need to wait for the formal Annual Enrollment Period. Any changes made to their plans will be applied the following month.[7]

The U.S. Department of Health and Human Services estimates that more than a quarter of Part D participants stop following their prescribed regimen of drugs when they hit the doughnut hole.[10]

Every Part D plan sponsor must offer at least one basic Part D plan. They may also offer enhanced plans that provide additional benefits. For 2008, the percentage of stand-alone Part D (PDP) plans offering some form of coverage within the doughnut hole rose to 29 percent, up from 15 percent in 2006. The percentage of Medicare Advantage/Part D plans (MA-PD) plans offering some form of coverage in the coverage gap is 51 percent, up from 28 percent in 2006. The most common forms of gap coverage cover generic drugs only.[11]

Among Medicare Part D enrollees in 2007 who were not eligible for the low-income subsidies, 26 percent had spending high enough to reach the coverage gap. Fifteen percent of those reaching the coverage gap (four percent overall) had spending high enough to reach the catastrophic coverage level. Enrollees reaching the coverage gap stayed in the gap for just over four months on average.[12]

According to a study done in 2007, premiums for plans offering gap coverage are roughly double those of defined standard plans. The average monthly premium for stand-alone Part D plans (PDPs) with basic benefits that do not offer gap coverage are $30.14. The average monthly premium for plans that do offer some gap coverage is $63.29. In 2007, eight percent of beneficiaries enrolled in a PDP chose one with some gap coverage. Among beneficiaries in MA-PD plans, enrollment in plans offering gap coverage was 33 percent (up from 27 percent in 2006).[11]

The Affordable Care Act (ACA), which was passed in 2010, ensured that the coverage gap or, so-called "doughnut hole", would be closing for patients on Medicare Part D. From 2017 to 2020, brand-name drug manufacturers and the federal government will be responsible for providing subsidies to patients in the doughnut hole.[13]

In an effort to close the coverage cap, in 2010, the Affordable Care Act provided a $250 rebate check for individuals whose drug expenses took them into the doughnut hole. The United States Department of Health and Human Services began mailing rebate checks in 2010.[10] Starting in 2011 until 2020, the coinsurance paid for prescriptions while in the coverage gap will decrease at a rate of 7% annually until beneficiaries will pay no more than 25% of the drug cost for their generic and brand name prescription purchases.[14] For instance, a 50% mark down off brand-name medications financed by the manufacturer and a 7% mark down off generic drugs by the government was introduced in 2011 for patients in the doughnut hole. These reductions on generic drug costs will continue to incrementally rise at a rate of 7% until 2019. The following year in 2020, an extra cost reduction will be imposed at 12%, equating to a total of 75% of the generic drug cost covered.[13] Similarly, for brand name drugs, the government will provide a subsidy at a rate of 2.5% beginning in 2013 and escalating to 25% in 2020. Thus, by 2020, Medicare Part D patients will only be responsible for paying 25% of the cost of covered generic and brand name prescription medications following payment of their deductible that year. Moreover, once patients enter the catastrophic threshold, they are only responsible for 5% of the drug cost.[13]

• cms.gov, the official website of the Centers for Medicare and Medicaid Services
  • Medicare at cms.gov
• Medicare.gov — the official website for people with Medicare
• How Stuff Works – Medicare