Legislative Update: July 2016

Legislative Update: July 2016

28% Of Medicare Beneficiaries Hit Doughnut Hole In 2015

By Jessie Gibbons, Senior Policy Analyst

The Medicare Part D “doughnut hole” – the gap in coverage that occurs when beneficiaries reach their initial annual payment limit – is costing many older Americans thousands of dollars per year.  Not all beneficiaries hit the limit each year, but in a recent survey of TSCL’s members and supporters, we learned that 28%, more than one-in-four respondents, fell into the doughnut hole in 2015.

Here’s how the coverage gap works.  Once individuals and their Medicare Part D plans spend the initial coverage amount ($3,310 in 2016) on covered prescription drugs in a calendar year, beneficiaries hit the doughnut hole.  Once in the doughnut hole, coinsurance on covered drugs is not only higher, one must also pay a substantial amount out-of-pocket to reach the limit for catastrophic coverage.  For brand-name drugs in the coverage gap, individuals are responsible for 45% of the cost, and for generic drugs, they’re responsible for 58%.  Once out-of-pocket costs for those in the doughnut hole total $4,850, catastrophic drug coverage takes effect, and Part D plans pay 95% of prescription drug costs until the calendar year ends.

The Affordable Care Act made changes that slowly close the doughnut hole, but it’s a lot like trying to fill a bathtub when the drain is still open.  In 2017, those who fall into the coverage gap will have lower coinsurance, paying 40% of brand-name prices and 51% of generic prices.  In 2018, those numbers will fall to 35% and 44%, respectively. And in 2020, they will be responsible for the standard 25% of the costs of both brand-name and generic drugs.  However, beneficiaries will continue to be saddled with an ever-growing out-of-pocket maximum that must be paid before catastrophic coverage begins.  Over the next eight years, that maximum will grow from this year’s $4,850 to $8,300 in 2024.

Thus beneficiaries will continue to be hit with steep costs when they fall into the coverage gap in the foreseeable future.  To keep prices as low as possible in the doughnut hole, beneficiaries can look into using mail-order pharmacies, which require 90-day prescriptions and are often cheaper per dose than a 30-day supply.  People with limited incomes may also qualify for Extra Help or other pharmaceutical assistance programs. TSCL also recommends that Part D beneficiaries talk to their doctors at each visit to discuss potential alternatives to their high-cost prescriptions.

In the meantime, TSCL is advocating on Capitol Hill for legislation that would provide immediate assistance to those who fall into the coverage gap.  Older Americans living on fixed incomes cannot wait until 2020 for coinsurance in the doughnut hole to drop to 25%.  We enthusiastically support the Prescription Drug Affordability Act (S. 2023, H.R. 3513), a bill that would drop the coinsurance to 25% by 2017, three years earlier than current law would.  In the months ahead, we will continue to work with its sponsors in the House and Senate to build support for it, and we hope to see it passed into law by the end of this year.

For updates on the progress of the Prescription Drug Affordability Act or for more information about the Medicare Part D doughnut hole, visit our website at www.SeniorsLeague.org or find us on Facebook and Twitter.