Medicare Donut Hole Explained Simply
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- Опубліковано 27 сер 2020
- Medicare Donut Hole Explained Simply // Need help understanding the coverage gap? In this video, Medicare School Daily will discuss the Medicare part D donut hole. Is it hard understanding Medicare’s part D donut hole? MedicareSchool.com wants to help you learn how to avoid the donut hole with your Medicare prescription drug plan. We will help you in understanding your costs in the Medicare donut hole and your medicare part D plans.
With so much conflicting and confusing information surrounding Medicare, it’s easy to feel unsure about how to choose the best plan(s). At MedicareSchool.com, we empower you with the knowledge and guidance you need to get the best Medicare plans and live retirement worry-free.
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• Medicare Donut Hole Ex...
We hope that this video of the Medicare Donut hole explained simply helped answer all of your questions! What did you learn about the donut hole?
I didn’t even know the donut hole existed! Thank you for explaining it so clearly!!!
Been watching your videos, recommended by friend. I would reach my donut hole in about 30 days. Your suggestions are fine for normal people. When you have serious illness it does not work. My meds out of pocket per year without insurance is $65,000. I make 19,000 in Disability/Social Security and no longer will qualify for extra help. FYI most doctors can do samples one month or two.
Short response is people like me don't get what we need and eventually die.
So sorry to hear of your troubles, thank you for your feedback.
thankyou they were talking about this at work during training and it sounded like another language. You made it simple to understand wish you were my Medicare trainer lol.
Well Done !
Thank you so much for this explanation. I’m not sure if I understand correctly but having a plan with a deductible will End up being cheaper then say a plan that has $0 deductible?
im in nursing school and have a community health exam tommorow and need to know this. this was so helpful thank you!
Glad we were able to help! Good luck on your exam! My daughter-in-law is a nurse! Great profession and always needed
Clear and concise explanation. Thanks!
You're welcome!
Thank you so much for explaining it easy way!!!
You’re welcome! Let me know if I may help further. 800-864-8890
Sir, for someone like myself, who has apparently entered this donut hole, would the type of Medicare Advantage plan have any effect on it? Would this happen with any plan?
THANK YOU SOOO MUCH FOR ALL THE INFO
You are so welcome!
Helped a lot, thank you sir.
You're welcome!
Thanks 🙏
You're welcome! Thanks for watching!
Clear explanation. I Will look if you have a video on HMO vs PPO plans.... Dental is also important to me... will look into that, maybe even call you. Thanks!
Thank you - that is our goal! We strive to explain all the different parts of Medicare so that people can feel confident about their Medicare choices. We do have several videos that talk about advantage plans, which mentions HMO and PPO plans. I also have a brief video about dental as well. We are more than happy to help answer your questions and help you find the best plans for you. You can call 800-864-8890 to talk to a Medicare Guide free of charge.
Advantage Plan:
ua-cam.com/video/7niUDlwi2Ow/v-deo.html
ua-cam.com/video/5OmK94JRerc/v-deo.html
ua-cam.com/video/BebQ04cKzJc/v-deo.html
ua-cam.com/video/z8LlA6wAp5M/v-deo.html
ua-cam.com/video/Az5RBfJGMYg/v-deo.html
Dental:
ua-cam.com/video/SKA9TR79GMU/v-deo.html
I am not yet on Medicare but will be soon and all of this is scaring the daylights out of me. I have insurance through the Marketplace right now covering myself, husband and son that costs only $140 a month. I take 4 meds daily. On one of the pharmacy receipts it said “your insurance saved you $367.” That’s for a generic medicine! That donut hole is a nightmare to me.
When do you start Medicare? It can be overwhelming. We'd love to be of assistance in any way we can.
great video
Glad you enjoyed it
omg I get it now.. why do people make it more complicated than it is!?
What a scam insurance companies use retail values to bump up your costs when they dont pay retail. Typical insurance rip off.
True.
If you switch plans does this reset the donut hole?
Once a person enters the donut hole, is it too late to reverse that (get out) in the same year, by going to as many generic drugs as possible, or would any changes in the retail prices of the drugs only apply to the following year?
It’s too late to reverse, but it would save you money. 25% of a generic medication is less than that of a name brand one.
You mentioned regarding donut hole that it is calculated on retail price. Isn’t Medicare’s portion per prescription a negotiated price, which would be less than what we would pay with cash and no coupon like GoodRX?
Because that would mean they’re counting dollars that they did not put towards the expense of our prescription, when they calculate our $4000+ figure.
So to estimate how soon I would go into the donut hole, would I look at last year’s pharmacy receipts from my Marketplace plan and see what the retail price is for my meds?
If you call us, we can walk you through your particular situation and give you costs? But yes, you're right that some of Medicares portion will be negotiated.
I tried using a coupon that I got from a doctor and it says if you are on Medicare or it actually said a government assistance which is Medicare then you cannot use a coupon. I talked to the pharmacist and they really try to work with us but they never mentioned trying to pay cash. Mom is on eliquis januvia and a heart medicine for AFib I can't remember the name of. All three of these put us out. Thank goodness our pharmacy lets us put things on a bill so we can pay them at a later time. I've had to get into some savings to pay for her meds at some point. We both live on her social security so it makes it really tight when this happens. So far the only samples I can get are eliquis.
You can call the manufacturer of the drug and ask them for help. Also, check to see if either of you or both of you qualify for Medicaid.
Hello! Thank you for this video! My dad’s Medicare plan enters him into the donut hole after the price of his medications paid by him (co-pays) and the insurance (retail price) equal $4,430. His plan says that he will leave the coverage gap (donut hole) after his YEARLY drug costs equal $7,050. My understanding is that the $4,430 is part of the $7,050 yearly total, but someone told me otherwise. Do you have any insight into this? Thank you!
It’s a good question… the $4,430 is not part of it. The $4,430 is the cumulative retail amount of his meds that pushes him into the coverage gap. What is part of the $7,050 is what he has paid in deductible ($480), copays from stage 2, the 25% he’s paying in the donut hole, and a 50% ish manufacturers discount. Once that all ads up to equal $7,050 then he moves on to catastrophic where meds cost 5%.
@@MedicareSchool, thank you! He actually doesn’t have a deductible so, if I look at all his EOBs for the year within the initial coverage phase/stage 2, that will show me all the co-pays (only the ones for prescriptions count for the donut hole-right?) he has paid to help estimate his remaining costs to get out of the donut hole-right? Can you further explain the 50% manufacturer discount that applies toward the $7,050? The insurance company told me that his one medication costs $2,500 total-they are paying $2,000 in the donut hole and he will have to pay $500. I was told that the full $2,500 goes toward the $7,050-does that sound accurate?
That does sound right. We have a site that you can punch in the meds and see all the details of the different stages with his medications. MedicareSchoolEnroll.com. You can create a username / password and store meds in it and use it anytime.
@@MedicareSchool Great video and info So glad I read the comments, almost asked the identical question. Can you explain what you mean by 50% manufacturers discount? Is this something i'm aware of or does this discount take place behind the scenes and Medicare is tracking it? Thanks 👍
As a French person this horrifies me but thanks for the clear explanation I needed it for my English test tomorrow 👍
Best of luck!
Great tutorial! Could you please explain further on how to get out of the donut hole? Is there a $$ threshold to meet?
Yes. It’s called the True Out of Pocket Cost and that number is 6,550 for 2021. It does not include the previous threshold of 4,130 to enter the donut hole(stage 3). What goes into the 6,550 is the deductible amount(stage 1, and generally $445 in 2021) + the copays you’ve paid in stage 2 (the initial coverage stage) + a 70% manufacturer’s discount on the medication. When those amounts add up to equal $6,550 you enter catastrophic coverage and medications are inexpensive (you pay about 5% of the retail cost). The nice thing is, there are tools that allow us to compare all the plans so you can know which drug plan is the lowest out of pocket for you. Call 800-864-8890 if you need such a comparison done.
what does it mean takes a while to do that 3:48 ? how do you get to the 5% cost level?
You get to stage four when your out of pocket costs reach 6,550. That includes the deductible from stage 1, the copays from stage 2, your 25% from stage 3 + a manufacturers discount of about 70% of the retail cost in stage 3. When all that adds up to equal 6,550 you go into stage 4 and meds cost goes way down.
Is this info still correct in regards to retail threshold in stage 2?
These are the numbers for 2023. They will more than likely be changing for 2024
I have only one prescription that costs only $10.00 if I paid for it out of my own pocket. Would I still have a high deductible??
Probably not!
What about low income subsidy ? Does the donut apply to them ?
No, It doesn't apply to people who qualify for the Extra Help.
If you have any questions please, feel free to give us a call at 800-864-8890 or schedule a free appointment here:
www.medicareschool.com/talk-to-a-guide?rc
What needs to happen to get out of the donut hole.
My team would be happy to assist you with setting up your Medicare coverage. Give us a call at 800-864-8890 or schedule an appointment at www.medicareschool.com
If a drug company lowers the retail price of a medicine and you have already paid a bunch of copay, does that push you into the donut hole? Just spitballing.
I'm not sure if I follow... can you rephrase?
@@MedicareSchool I'm not sure what I was asking, I was trying to understand how a person who takes outrageously expensive medication would figure in this situation. If it's almost the deductible and buying one pill (for example) matches the market price, then what happens?
If they lower the retail cost you will just have to pay less while you are in the donut hole AND it would take longer to get into the donut hole.