These are some of the changes that you will see for Medicare Part D in 2018.

The standard Deductible will increase by $5.00. The standard Part D Deductible will be $405 for 2018.

What does this mean to you?

If your Medicare Part D Rx drug plan has a deductible, you may pay $5 more out-of-pocket in 2018 before you did in 2017. Most Part D plans exclude lower-cost Tier 1 and Tier 2 prescriptions from the deductible, giving you coverage for lower cost generic medications before you need to meet your deductible.

Beginning January 1, 2018 your Initial Coverage Limit (ICL) will increase $50 to $3,750.

This means that you will be able to buy slightly more medications before reaching the 2018 Donut Hole or Coverage Gap.  A good rule of thumb is that if the full retail cost of your medications is less than $312 per month, you will not enter the Donut Hole.

The Donut Hole discount will increase for both brand-name and generic drugs.

The generic drug discount you get while in the Donut Hole will increase from 49% to 56% and the discount for brand-name drugs will increase from 60% to 65%. So, if your brand-name medication has a retail cost of $400, you will pay $140 for your medication while in the Donut Hole.

Total Out-of-Pocket Costs will increase by $50.

The TrOOP or your total out-of-pocket cost is the dollar figure you must spend to get out of the Donut Hole or Coverage Gap, not including your monthly premium. The 2018 TrOOP will now be $5,000 in 2018.

What is the end result?

In 2018, you will have to spend only a little bit more to get out of the Donut Hole than you did in 2017.  So, to get out of the Donut Hole your total retail medication need to be over $702 per month. In which case you will enter the Catastrophic Coverage phase where you will remain for the rest of the year.

Once you enter the Catastrophic Coverage phase you will pay either 5% of the total retail cost of the drug OR $8.35 for brand-names and $3.35 for generics, whichever is higher.

If you need a more in-depth explanation of how Part D works or want to review what plans will help you avoid the Donut Hole, give me a call. My number is 207-370-0143. I will be happy to help you.

Be sure to read your Annual Notice of Change Letter (ANOC) that should arrive in the mail each year at the beginning of October to see how your plan is increasing – this may help you determine how much you need to budget in 2018 to cover the costs of coverage. [READ MORE …]

If you would like to talk to me, ask a question or schedule a meeting at your home or a nearby meeting place, you can call me directly at 207-370-0143 or use my simple form on the CONTACT page of this site to send an email message.

The best part about working with me is that it does not cost you anything to talk with me to discuss your options and review the plans that are available. I am paid by the insurance companies in the form of a commission when you enroll in a plan.  You pay nothing.

And you will not pay any more than anyone else and you are under no obligation whatsoever to change your plan if you talk with me.

“My goal is to help people and I have found great joy in being able to offer my services to people who need my help.”

3 things to know about the Annual Notice of Change (ANOC)

Avoid surprises – Review your Annual Notice of Change each fall!

If you have a Medicare Advantage plan (Part C) you will receive an Annual Notice of Change (ANOC) from your health insurance company at the end of September. If you are new to Medicare, then you may not know what this is.

Who gets one and what should you do with it?

The ANOC is an important notice sent each year to people who have a Medicare Advantage (MA) Plan or a Medicare Part D Prescription Drug Plan.

The health insurance companies that administer these plans are required to send notices to you each year to notify you of cost and/or benefit changes that will take effect starting January 1, 2018.

When should you expect it?

You should receive this notice by September 30th of this year. If you haven’t received it by then, you should contact your plan to ask for it or call your agent to learn about what is changing. Your agent will know everything that is changing and can explain how it will effect you.

If there are changes to your costs and benefits that could raise your costs or get in the way of getting the health care you need, you may want to think about making changes to your Medicare coverage during Medicare’s Fall Open Enrollment Period.

When can you make changes?

Fall Open Enrollment runs from October 15 to December 7 every year. If you make changes to your Medicare coverage during Fall Open Enrollment this year, they will go into effect on January 1, 2018.

Even if you review these notices and decide that there won’t be any major changes to your Medicare coverage in 2018, it still might be helpful to look at other Medicare options and compare them to your current plan.

Another plan in your area might offer health and/or drug coverage at a better price than what you currently pay. To learn more about different Medicare coverage options, call 1-800-MEDICARE or use the Plan Finder tool at medicare.gov or click this link.

Educate yourself on these common Medicare myths — both your health and your wallet will thank you.

Medicare is a great program. I know because I meet with people every day who are turning 65 and entering the Medicare system and looking for help and advice on where to start and what to look for.  Medicare saves you from having to pay enormously high private health-insurance premiums, and it protects you from catastrophic medical expenses. But if you’ve heard one of these common misunderstandings about Medicare, you will be glad you found this website.

1. Medicare enrollment happens automatically at 65

Everyone becomes eligible for Medicare at age 65, but actually enrolling in the program is up to you. The only way you’ll be automatically enrolled in Medicare is if you’re already receiving Social Security benefits when you hit your 65th birthday or if you are collecting Social Security Disability payments. In either of these cases, you’ll be enrolled in Medicare Part A (hospital insurance) and Part B (medical insurance) as soon as you become eligible, although it’s still up to you to sign up for any prescription drug coverage, Medigap, or a Medicare Advantage plan. — That’s where I come in!

Read more about How and When to Enroll.

2. You can enroll any time after age 65

This is not quite accurate. Your initial enrollment period for Medicare begins three months prior to your 65th birthday and ends three months after the month which you turned 65. If you don’t enroll during this seven-month period, you’ll have to wait for the next Medicare open enrollment period which happens between January 1 and March 31 and your Medicare benefit will begin on July 1st. And if you are enrolling in a Medicare plan it must be done prior to July 1st!

There are also penalties for late enrollment. If you don’t sign up for Part A during your initial enrollment window, then your monthly premium will go up by 10% for twice the number of years you could have been enrolled but were not. For example, if you file for Medicare Part A three years after you become eligible, then you’ll have to pay a higher premium for six years.

You should also sign up for Part B as soon as you’re eligible. If you don’t, your premium will go up 10% for every year you delayed — permanently.

Read more about How to Correctly Plan Your Enrollment.

3. Medicare is free

This is a big one! Especially with all the advertisements out there saying that plans have no cost or $0 monthly premiums.

Some parts of Medicare and some covered services are indeed free, but there are certainly some costs involved. Medicare Part A, which covers in-patient hospital stays, has no monthly premium if you worked (and paid Medicare taxes) for at least 40 calendar quarters (or 10 years) by the time you enroll. Medicare Part B, which covers outpatient doctor visits, routine bloodwork and similar expenses, has a premium of $134 per month in 2017, although high-income enrollees may pay higher premiums.

Other Medicare parts and plans have a wider range of premiums, often based on the type of plan and where you go for care. As for services, different Medicare parts and plans offer different levels of coverage for various medical expenses. Some expenses may be completely covered by Medicare, such as an annual wellness exam, while others require you to pay a co-pay or meet an annual deductible.

Read more about How can insurance can have a $0 premium?

4. Medicare covers all types of healthcare expenses

The different parts of Medicare cover different types of healthcare. Medicare Part A covers only hospital-related services, while Part B covers other types of medical expenses such as doctors’ visits and lab tests. Part D covers prescription expenses.

Part C, also known as Medicare Advantage, can cover additional services such as vision and dental care. Medigap plans help cover some of the costs that Medicare Part A and Part B don’t cover, but it doesn’t include prescription coverage, dental, vision, and so on. So the exact coverage you have will depend on which parts of Medicare and which specific plans you sign up for.

5. You may not qualify for Medicare

Happily, you cannot be rejected from Medicare coverage just for being sick or having a pre-existing condition. For that matter, pre-existing conditions won’t raise your premiums, either. This should continue to be the case for Medicare even if Congress repeals the Affordable Care Act’s pre-existing condition clause.

Still have questions or want help comparing the different health insurance plans?  I can help you!

Are you turning 65 and still working?  Read this.

There is no obligation to you and no cost to meet with someone.

Popular Donut Hole Questions

During this time of year, many people will begin to enter the Coverage Gap or “Donut Hole” portion of their Medicare Part D coverage and find their coverage costs changing.

If you have already purchased medications with a retail value of $4,020 you are in the 2020 Donut Hole.

Question:  I have purchased medications worth $3,930 so far this year, my next brand-name drug purchase has a retail cost of $400, bringing me into the Donut Hole (or Coverage Gap).  Will I get a Donut Hole discount on the full $400 retail price or just the $90 that falls into the gap?

Your Donut Hole discount (which is 25%) only applies to the $90 portion of the retail drug price that falls into the Coverage Gap.  Since your purchase “straddles” two phases of coverage, you pay your cost-sharing for the Initial Coverage phase (for example, $47 for a Tier 3 brand drug) and the brand-name Donut Hole discount applies to the remainder of the retail price falling into the Donut Hole.

Therefore, your total drug cost is the cost-sharing you paid in the Initial Coverage phase plus the discounted cost in Donut Hole. (Note: The combined cost of the Initial Coverage phase and the Donut Hole phase will never exceed your drugs total retail cost.)

Question:  If I use only one brand drug that costs $347 and have a $47 co-pay, will I enter the 2020 Donut Hole?

Yes. If your retail drug costs average $347 you will exceed your Medicare plan’s Initial Coverage Limit of $4,020 and enter the 2020 Coverage Gap or Donut Hole sometime in November.

Only your plan’s retail drug costs count toward entering the Donut Hole. Your co-pay has no impact on entering the Donut Hole, but will impact when you exit the Donut Hole.

Question:  I am in the Donut Hole and now have a new prescription that is not on my plan’s list of covered drugs.  Do I get a discount on my new medication and will my costs count toward getting out of the Donut Hole?

No. Only Medicare Part D prescription medications found on your plan’s formulary receive the 75% discount. Non-formulary medications and medications excluded from the Medicare Part D program, do not qualify for the Donut Hole discount and your non-formulary drug purchases do not count toward meeting your 2020 total out-of-pocket drug spending (TrOOP) limit of $6,350 — the amount you need to spend to exit the Donut Hole.

If you are using a non-formulary medication, you can ask your Medicare plan for a Formulary Exception which is a type of Coverage Determination.

If your Medicare Part D plan denies your request, you have the right to appeal your plan’s decision.  For more information, you can click here to read about Formulary Exceptions. https://www.cms.gov/Medicare/Appeals-and-Grievances/MedPrescriptDrugApplGriev/Exceptions.html

Do you have a question not answered here?

Click here to ask a question.

Medicare Part C is available through Medicare Advantage plans, and is an alternative to Original Medicare (Parts A and Part B). Medicare Advantage plans are health insurance plans offered by private health insurance companies approved by Medicare. Medicare Advantage health plans (such as HMO, PPO or PFFS plans) are legally required to offer at least the same benefits as Original Medicare, but can include additional coverage as well, such as routine vision or dental benefits, health wellness programs, or prescription drugs.

One benefit of Medicare Advantage plans is that you can get your prescription drug benefits (Medicare Part D) included under the same plan, instead of having to enroll in a separate stand-alone Medicare Prescription Drug Plan. These plans give you the convenience of having your Medicare Part A, Part B, and Part D coverage through a single plan.

Medicare Advantage plan costs and coverage details can vary depending on the insurance company and county that you live in.

What are the different types of Medicare Advantage plans?

As mentioned, Medicare Part C coverage details can vary depending on the insurance company, so it’s always a good idea to compare the Medicare Advantage plan options in your specific location. The following are types of Medicare Advantage plans that may be available in your location:

Health Maintenance Organization (HMO) plans: These plans offer a network of doctors and hospitals that members are generally required to use to be covered. Because of this, HMOs tend to have strict guidelines, meaning that any visits and prescriptions are subject to the plan approval. If you use providers outside of the plan network, you may need to pay the full cost out of pocket (with the exception of emergency or urgent care). You generally need to get a referral from your primary care doctor to see a specialist.

Preferred Provider Organization (PPO) plans: Medicare Advantage PPO plans offer a network of doctors and hospitals for beneficiaries to choose from. Unlike an HMO, you have the option to receive care from health-care providers outside of the plan’s network, but you’ll pay higher out-of-pocket costs. Medicare Advantage PPOs don’t require you to have a primary care doctor, and you don’t need referrals for specialist care.

Private Fee-for-Service (PFFS) plans: This type of plan allows visits to any Medicare-approved doctor or hospital, as long as the plan’s terms and conditions of payment are accepted by the provider. Keep in mind that you’ll need to find providers that contract with the plan each time you are receiving treatment.

Special Needs Plans (SNPs): These plans limit enrollment to beneficiaries who have certain chronic conditions, are institutionalized, or qualify for both Medicare and state Medicaid (also known as dual eligibles). Benefits, provider options, and prescription drugs are tailored to meet the needs of the plan’s enrollees.

How do I know if I am eligible for a Medicare Advantage plan?

In order to be eligible for Medicare Part C, you must be enrolled in both parts of Original Medicare (Part A and Part B). Once you have Medicare Part A and Part B, you are generally able to enroll in a Medicare Advantage plan, provided you live in the plan’s service area and do not have end-stage renal disease (ESRD).

There are some exceptions where you may be able to enroll in a Medicare Advantage plan even if you have end-stage renal disease. For example, if you’re enrolling in a Special Needs Plan that targets beneficiaries with end-stage renal disease, you may be eligible to enroll in this type of Medicare Advantage plan.

To learn more about other situations where you may be eligible for Medicare Part C if you have end-stage renal disease, you can contact us using the contact page on this site. You can also contact Medicare at 1-800-MEDICARE (633-4227); 24 hours a day, seven days a week.

Those with other health insurance coverage (a union or employer-sponsored health plan, for example) should get more information about their existing coverage before enrolling in a Medicare Advantage plan. It is possible you could lose your existing coverage once you enroll in a Medicare Advantage plan. Furthermore, if you discontinue the other plan for Medicare Part C coverage, you may not be able to reinstate your original coverage if you change your mind. It is generally a good idea to check with your current benefits administrator before you enroll in another health-care plan.

Read more about other types of plans and options …