| Tue, May 15, 2012 @ 09:00 AM

Are There Gaps in Your Medicare Knowledge?

Posted by Medicare Made Clear

Are There Gaps in Your Medicare Knowledge?

When you’re looking at Medicare coverage for you or a loved one, you might notice the term “gap” coming up often. You’ve probably also noticed this can refer to a few different things in Medicare. When you’re trying to understand what “gap” means, it might be helpful to think about types of coverage. Are you looking at Medicare coverage overall, or specifically at Part D prescription drug coverage? This can help you know which gaps to fill in and which to avoid or delay.

Filling the gaps left by Original Medicare

Medicare Part A and Part B, which is sometimes called “Original Medicare,” goes a long way to covering your hospital and medical expenses, but it won’t cover everything. This can lead to two main types of “gaps” you might need to fill.

Benefits gap: Original Medicare Parts A and B covers many hospital and medical expenses. But what about extra benefits? Maybe you need dental coverage or wellness services. Maybe you’d like a plan that includes a prescription drug benefit. In other words, there might be a “gap” between the coverage you want and the coverage you may get from Original Medicare. If this is the case for you, it might be worth taking a look at Medicare Advantage plans (Part C).

Briefly, Medicare Advantage plans offer all the same coverage as Original Medicare Parts A and B plus the extras you might be missing, like dental coverage, wellness services or prescription drug coverage. Each plan is different, so be sure to do your research to get the plan that best fills your specific benefits gaps.

Cost gap: Even if Original Medicare Parts A and B provide the coverage you need, you might notice a gap between what it will pay for and what you have to pay out of your own pocket. One way to help fill this type of gap is with a Medicare supplement insurance plan. In general, these plans help pay for some of the out-of-pocket expenses that Medicare Parts A and B don’t cover. When deciding if a Medicare supplement insurance plan might be a good choice for you, remember that each plan is different, and not all plans are available in all states.

Understanding the Medicare Part D Coverage Gap

If you have Medicare Part D prescription drug coverage, or if you’re looking at getting it, you’ve probably seen the term “coverage gap” (also known as the “doughnut hole”). No matter what type of prescription drug coverage you have, it will include cost sharing. Knowing how the coverage gap works can help you better understand your costs. One way to go about this is to look at the drug payment stages.

Stage 1: Initial Coverage Period

You share costs with the plan, usually as copays until your combined total hits $2,930 (2012).  This figure can vary by plan.

Stage 2: Coverage Gap

After you reach $2,930 (2012) in total drug costs, you pay 86% of the cost of generic drugs and about 50% of the cost of most brand-name drugs. This goes on until your yearly drug costs hit $4,700 (2012). Since you pay most of the costs during this time and your plan pays a few, this is the Coverage Gap (or “doughnut hole”).

Stage 3: Catastrophic Coverage

You pay a small copay or coinsurance on all your drugs until the year’s end. The plan pays the rest. At this stage, there is no limit to the amount the plan pays.

Some people may be able to avoid or delay the coverage gap. It’s important to keep the lines of communication open with your doctor. Are there less-expensive versions of the drugs you’re currently taking (e.g., generics)? Are there any prescriptions you might not need to take as often if at all? Maybe there are lifestyle changes you can make to reduce the need for certain prescriptions now and in the future?

Another way to help keep your costs down is to be sure to get your prescriptions filled at one of your plan’s network pharmacies. This is especially important if you enter the coverage gap. Learn more about closing the coverage gap with this handy Medicare.gov publication.

Putting it All Together

Understanding the different meanings of “gap” in Medicare can help you better understand your needs or your current coverage. Learning more can help you avoid, delay or fill these gaps, which could save you money and make sure you have the coverage you need.

For more information, contact the Medicare helpline 24 hours a day, seven days a week at 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048. If you have questions about Medicare Made Clear call 1-877-619-5582, TTY 711, 8 a.m. – 8 p.m. local time, seven days a week.


MedicareMadeClear: Understanding Medicare Advantage plans (Part C)

MedicareMadeClear: Understanding Medicare Part D

Medicare.gov publication Closing the Coverage Gap

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