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Understanding MOC Requirements
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The Patient Protection and Affordable Care Act (PPACA) began
making changes to the Medicare Part D Prescription Drug Program in
What is the Medicare Part D Program coverage gap ("donut
hole") and how does the PPACA reduce beneficiaries' out-of-pocket
costs within the gap?
In 2010, the standard Medicare Part D benefit includes a $310
deductible and a 25 percent coinsurance until the enrollee reaches
$2,830 in total covered drug spending. After this initial coverage
limit is reached, there is a gap in coverage in which the enrollee
is responsible for the full cost of the drugs (often called the
donut hole) until total costs hit the catastrophic
threshold, $6,440. It is estimated that about 25 percent of
beneficiaries reach the coverage gap in a given year. Once reaching
the catastrophic threshold, beneficiaries are covered for at least
95 percent of their drug expenses for the rest of the year.
Beginning in 2011, the PPACA requires that drug manufacturers
provide a 50 percent discount on brand name prescriptions while the
beneficiary is in the coverage gap. In addition, Medicare total
cost calculations will include the non-discount price of the drugs;
thus beneficiaries will be able to reach the catastrophic threshold
more quickly while benefiting from decreased out-of-pocket
Also beginning in 2011, a federal subsidy is phased in for
generic drugs so that the coinsurance is reduced from 100 percent
to 25 percent within the coverage gap by 2020.
Beginning in 2013, a federal subsidy is phased in for generic
drugs so that the coinsurance is reduced from 100 percent to 25
percent within the coverage gap by 2020. This is in addition to the
50 percent discount on brand prescriptions within the coverage gap
that is implemented in 2011.
Are there any other changes in the Medicare Part D
Prescription Drug Program that will reduce beneficiary drug costs
or increase drug access?
The PPACA contains several provisions to be implemented in or by
2011 that are designed to improve access to and availability of a
federal low-income supplement (LIS) to Medicare beneficiaries with
incomes below 150 percent of poverty. For example, the
redetermination of LIS eligibility subsequent to the death of a
spouse would be postponed for a year, and cost sharing would be
eliminated for individuals receiving care under a Medicaid home and
community based waiver who would otherwise require care in a
medical institution or a facility. The PPACA also makes changes to
the methodology used to determine which drug plans are eligible to
enroll low-income beneficiaries so that more plans could qualify
and thus reduce the number of low-income beneficiaries who need to
change plans from year to year.
Is it true that some beneficiaries will be required to
pay higher premiums to join a Medicare Part D Prescription Drug
Yes, similar to the change made in 2007 requiring high-income
beneficiaries (in 2009 defined as an individual earning $85,000 or
couple $170,000) to pay higher premiums for Part B benefits, the
PPACA, effective January 1, 2011, sets the same thresholds for Part
D plan premium payments.