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2019 Medicare Donut Hole: Part D Changes and Costs

According to the Henry J Kaiser Family Foundation (KFF), 43 million Medicare beneficiaries are enrolled in a Part D plan. This accounts for 72% of Medicare beneficiaries nationwide!

Medicare Part D started in 2006, and back then, you were required to pay 100% of the costs for brand name drugs. That percentage has lowered over the years, and better yet, 2020 brings super exciting news regarding the Medicare Part D donut hole.

Free Prescription Discount Card
Free Prescription Discount Card

How Does the Medicare Part D Donut Hole Work in 2019?

The Medicare donut hole is a gap in your Part D plan that starts after you’ve spent your deductible ($415 or less) and exceeded the initial coverage limit ($3,820) in total out-of-pocket costs.

You are in the gap until you reach the annual out-of-pocket threshold ($5,100). During this time, you are required to pay more for your prescriptions. This encourages you to choose generic options whenever possible.

Once you pass the donut hole and reach the catastrophic coverage period, you only have to pay 5% of all drug costs for the remainder of the year.

How Much Is the Donut Hole in 2019?

In 2019, you will pay 25% of brand-name drugs in the donut hole. This is the same as what you would pay before you enter the donut hole, meaning the Medicare donut hole is completely closed for brand-name drugs.

However, you will be responsible for up to 37% of generic drug costs in 2019. The plan is for this to decrease to a max of 25% in 2020, effectively closing the donut hole. Other Medicare donut hole 2019 costs include:

  • Initial Deductible: increasing by $10 ($405 to $415)
  • Initial Coverage Limit: increasing by $70 ($3,750 to $3,820)
  • Out-of-Pocket Threshold: increasing by $100 ($5,000 to $5,100)
Medicare Pharmacy
Medicare Prescription Drugs | Medicare Donut Hole 2020

How Will I Know If I’m in the Donut Hole?

In 2019, you’ll know if you’re in the donut hole based on your “EOB” notice. The EOB is an “Explanation of Benefits.” If you have a Part D plan, you should be receiving this every month.

The notice will tell you how much you’ve spent for the year on covered drugs and whether or not you’ve reached the coverage gap. Some people may never reach it – it depends on how much you’re spending on your prescriptions.

What Drugs are Covered in the Hole?

Your “formulary” does not change when you’re in the donut hole. The drugs that are listed on your formulary are the drugs that you can receive coverage for.

When Is the Donut Hole Going Away in 2020?

The Medicare Part D donut hole is scheduled to close completely in January 2020. Thanks to the Bipartisan Budget Act of 2018, the gap has closed a whole year ahead of schedule. However, the gap is only closing for brand-name drugs.

The gap for generic drugs will decrease, but will not be completely eliminated until 2020. This is great news for beneficiaries like you because generic drugs already have a lower price point – it’s the brand-name drugs that typically cause hardship in the donut hole.

What Will My Part D Costs Be in 2020?

The standard Part D deductible is $435 in 2020. After you meet the deductible, you’ll pay 25% of both brand name and generic drug prices.

Once you pay $4,020 out-of-pocket, you’ll still only pay 25% of your prescription drug costs, instead of entering the donut hole.

After you pay $6,350, you enter Catastrophic Coverage, and you’ll pay 5% of your prescription costs.

Medicare Pharmacist | Medicare Donut Hole 2020

What Are Your Medicare Part D Donut Hole Coverage Options?

Original Medicare (Part A and B) does not cover prescription drugs. If you are looking for prescription drug coverage, you have two options. You can enroll in either a Medicare Advantage or Part D plan.

If you are exclusively looking for prescription drug coverage, Part D may be right for you. If you are looking for prescription coverage along with other benefits like hearing, dental, or vision coverage, a Medicare Advantage plan is probably best for you.

Trying to decide between Medicare Advantage or a Part D plan can be difficult. Our licensed agents can help you enroll in the plan that best fits your unique needs and budget.

They can answer any questions or concerns you may have. Plus, our agents are contracted with most major carriers in your state, so there is no bias when we help you select a plan. If you’re interested in arranging a no-cost, no-obligation appointment, call us at 844-431-1832 or contact us here.

Contact Us | Medicare Plan Finder

This post was originally published on January 10, 2019, and updated on October 16, 2019.

A Guide to 5 Star Medicare Plans

There are 2,734 Medicare Advantage (MA) plans on the market nationwide in 2019. This is an increase of 417 plans since 2018! Based on location and eligibility, the average enrollee has 24 plan options, but only 10 percent of beneficiaries are enrolled in 5 star Medicare plans. These star ratings can help you understand the quality of services and care within the plan.

What is a Medicare 5 star rating?

Doctor and Patient | Medicare Plan Finder
Doctor and Patient | Medicare Plan Finder

Medicare has four main parts (A, B, C, and D), but not every part is rated. The Centers for Medicare and Medicaid Services (CMS) uses a rating system to rate Medicare Advantage and Part D plans. The rating system is as follows:

  • Five stars: Excellent
  • Four stars: Above average
  • Three stars: Average
  • Two stars: Below Average
  • One star: Poor

Medicare Advantage and Part D may have the same star system, but they have different factors that are weighted in the rating process. This is because they have primarily different purposes.

MA plans can provide additional benefits beyond Original Medicare like hearing, vision, or dental coverage. On the other hand, Part D plans provide prescription drug coverage.

Medicare Advantage plans are rated on the following factors:

  • Level of access to preventive services (including annual physical exams and screenings)
  • Care coordination
  • How often members receive treatment for long-term conditions
  • Current member satisfaction
  • Plan performance in comparison to the previous year
  • Customer service quality

Part D plans are rated on the following:

  • Number of member issues with the plan
  • How many people left over one year
  • Patient safety while using prescriptions in the plan
  • Accuracy of pricing
  • Quality of care
  • Customer service quality
Part D Checklist | Medicare Plan Finder
Part D Checklist | Medicare Plan Finder

What is a 5 star Medicare plan?

A 5 star plan is a plan with a 5 star rating! Rating information is released annually in October. You can review the ratings and compare plans here.

If a plan receives a rating below three stars for three consecutive years, it will be flagged by CMS. If the plan continues to rate poorly, it may be removed entirely from the marketplace.

This ensures that you are given the best plan options when you are enrolling. In 2019, most beneficiaries can enroll in a Medicare Advantage or Part D plan with four or more stars.

Are 5 Star Medicare Advantage Plans PPOs or HMOs?

Many Medicare Advantage carriers offer both PPOs (preferred provider organizations) and HMOs (health maintenance organizations). Both options provide top-quality healthcare services, but there are some differences:

  • HMO: With a HMO, you will need to select a primary care provider (PCP). Your PCP will need to make a referral in order for you to see a specialist.
  • PPO: You will not need to select a PCP with a PPO, nor do you need a referral to see a specialist in most cases.

The key difference that may help many people choose an option is cost. HMOs typically have lower monthly premiums than PPOs.

A licensed agent with Medicare Plan Finder can help you determine which type of plan is best for you. Our agents are highly trained and they can discuss the benefits of the plans in your area so you can make an informed decision.

Medicare Advantage | Medicare Plan Finder
Medicare Advantage | Medicare Plan Finder

5 Star Medicare Advantage and Part D Plan Carriers

5 Star Medicare Advantage plan (and Part D plan) carriers include:

  • Anthem
  • Cigna
  • Humana

Please note, ratings change annually, and each specific plan can have a different rating. We can not guarantee placement in a top-rated Medicare plan and this list is subject to change.

When can you enroll in a 5 star plan?

Several enrollment periods allow you to enroll in a Medicare Advantage plan, but did you know there is an enrollment period specific for 5 star plans?

5 Star Medicare Plans Special Enrollment

If you do not currently have top-rated Medicare Advantage plans available in your zip code, and a new plan becomes available, you can switch from your current plan to a 5 star plan even if it is not the Annual Enrollment Period. This means that you have a Special Enrollment Period. This enrollment period lasts from December 8 to November 20 of the following year. During this time you can:

  • Switch from Original Medicare to a 5 star plan
  • Change from a lower-rated plan to a 5 star plan
  • Switch between different 5 star plans

How to Find 5 Star Medicare Advantage Plans Near You

Are you looking for top-rated Medicare plans near you? Our licensed agents can answer any questions about how to enroll, when you can switch, and plans that are available to you.

Interested in arranging an appointment? There is no cost to you and never an obligation to enroll. Fill out this form or call us at 833-438-3676.

Contact Us | Medicare Plan Finder
Contact Us | Medicare Plan Finder

Shingles in the Elderly: Signs & Prevention

According to the Centers for Disease Control and Prevention, nearly one-third of people in the United States will develop shingles at some point in their life. The risk of developing shingles increases as you age and is more likely in those who have had the chickenpox (Varicella) virus. Prepare yourself now by learning everything you need to know about shingles in the elderly.

Shingles Complications

Shingles is caused by the varicella-zoster virus and results in painful blisters on your body. This is the same virus that causes chickenpox. If you had chickenpox, the virus remains inactive in nerve tissue near your spinal cord and brain. Years later, this virus can reactivate as shingles. What causes the dormant virus to reactivate? The exact reason is unclear, but researchers suggest that weakened immune systems, certain diseases such as HIV/AIDS or cancer, radiation, chemotherapy, and certain medications, like steroids, can contribute to the development.

Shingles can result in severe complications, the most common being postherpetic neuralgia (PHN). Those with PHN continue to have pain on the surface of their skin even after the blisters have subsided. PHN can take weeks, months, or even years to resolve. Other shingles complications include vision loss, facial paralysis, balance problems, and bacterial skin infections.

How long does shingles last in the elderly?

The average case of shingles lasts between three to five weeks. According to the National Institute on Aging, shingles follows a pattern. The first sign of shingles is often an itching or burning sensation on the side of the body. About one to five days later, a red rash will start to develop. A few days after that, the rash will turn into blisters. These blisters will last for roughly ten days before drying up and scabbing. Within a couple of weeks, the scabs should clear up. In some cases, shingles can then lead to other conditions (like PHN, mentioned above) that can last longer, but the shingles virus should clear up after about five weeks. Most people only get shingles one time, if at all, but it is possible to develop shingles more than once.

Shingles in the Elderly Symptoms

There is no cure for shingles, but early treatment can help fight the virus and limit the amount of pain you have. It’s important to understand the symptoms so you can talk to your doctor as soon as possible. Common shingles in the elderly symptoms include:

  • Burning, itching, or numbing area on the skin
  • Skin sensitivity
  • Itching
  • Fever
  • Headaches
  • Light sensitivity
  • Fatigue

Is shingles contagious to the elderly?

No. Shingles itself cannot be passed from one person to another. However, the virus that causes shingles can be spread through direct contact with the fluid from the blisters. A person with shingles is only contagious during the blistering phase. However, only those who have not had the chickenpox can contract the virus this way, and they would develop chickenpox as a result. Those who had chickenpox previously actually already have the virus, though it is inactive! If a person who has had chickenpox develops shingles, it will most likely be from the virus that is already in the body, not through contact with someone else who has shingles.

[click_to_tweet tweet=”Did you know nearly 95% of the U.S. population is at risk of having shingles due to the chickenpox virus in their body? https://www.medicareplanfinder.com/blog/shingles-in-the-elderly-signs-prevention” quote=”Did you know nearly 95% of the U.S. population is at risk of having shingles due to the chickenpox virus in their body?” theme=””]

Shingles in the Elderly Prevention

Preventing shingles can be difficult, especially since those who have had chickenpox already have the virus in their body! However, there is a vaccine that can drastically lower your risk of developing shingles. The vaccine is recommended for those over the age of 50 and it comes in two doses. The second dose should be administered between two to six months after the first. The shot doesn’t completely eliminate your risk for shingles, but it lowers your risk and can reduce the severity of the virus if it does surface.

Original Medicare (Part A and B) does not cover the shingles vaccine. However, a Medicare Advantage or Part D plan may cover it! These plans are great options that include coverage beyond Original Medicare and help you live the healthiest life possible! Our agents can help you understand all of your plan options and enroll you in a plan that fits your specific needs and budget. If you interested in arranging a no-cost, no-obligation appointment, fill out this form or call at us 833-438-3676.

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