The cost of your Medicare Part D-covered drugs may change throughout the year. If you notice that your drug prices have changed, it may be because you are in a different phase of Part D coverage. There are four different phases—or periods—of Part D coverage.
Deductible Period: Until you meet your Part D deductible, you are in the deductible period. During this time, you will pay the full negotiated price for your covered prescription drugs. While deductibles can vary from plan to plan, no plan’s deductible can be higher than $545 in 2024, and some plans have no deductible. You begin each new calendar year in the deductible.
Initial Coverage Period: After you meet your deductible, your plan will help pay for your covered prescription drugs. This is your initial coverage period. Your plan will pay some of the cost, and you will pay a copayment or coinsurance.
Coverage Gap: You enter the coverage gap when your total drug costs—including what you and your plan have paid for your drugs—reaches a certain limit. In 2024, that limit is $5,030. While in the coverage gap, you are responsible for 25% of the cost of your drugs. The coverage gap is also sometimes called the donut hole.
Catastrophic Coverage: In all Part D plans in 2024, you enter catastrophic coverage after you reach $8,000 in out-of-pocket costs for covered drugs. As of 2024, during this period, you owe no coinsurance or co-payments for the cost of your covered drugs for the remainder of the year. This puts a hard cap on your spending during the catastrophic phase of coverage. Before 2024, you paid 5% of the cost.
But what counts as an out-of-pocket cost? The out-of-pocket costs that help you reach catastrophic coverage include:
- Your deductible
- What you paid during the initial coverage period
- Almost the full cost of brand-name drugs (including the manufacturer’s discount) purchased during the coverage gap
- Amounts paid by others, like family members, most charities, and other persons on your behalf
- Amounts paid by State Pharmaceutical Assistance Programs (SPAPs), AIDS Drug Assistance Programs, and the Indian Health Service
Costs that do not help you reach catastrophic coverage include monthly premiums, what your plan pays toward drug costs, the cost of non-covered drugs, the cost of covered drugs from pharmacies outside your plan’s network, and the 75% generic discount.
- Your plan should keep track of how much money you have spent out of pocket for covered drugs and your progression through coverage periods. This information should appear in your monthly statements.
- Beginning in 2025, your out-of-pocket maximum for your Part D-covered prescription drugs will be reduced to $2,000. You will also have the option to pay out-of-pocket Part D costs in monthly payments spread over the year.
- Contact your State Health Insurance Assistance Program (SHIP) to see if you are eligible for programs that can lower your prescription drug costs. Contact information for your SHIP is on the last page of this document.
There are many types of pharmacy and prescription drug schemes. A few examples include:
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- You see charged on your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) charges for:
- Drugs that were never picked up, delivered, or even prescribed.
- Drugs (sometimes controlled drugs such as opioids) that were prescribed by a doctor you have never seen.
- Drugs beyond the amount you were prescribed.
- A different prescription drug, often one that costs more, than the one you were prescribed.
- A drug that is not approved by the U.S. Food and Drug Administration (FDA).
- A pharmacy purposely provided you with less medication than you were prescribed or expired drugs.
- A pharmacy gave you and billed for a costly compounded medication, such as a pain cream, when a lower cost prescription was ordered by your doctor.
- A pharmacy offers you “free” or “discount” drugs without an order from your doctor and then bills Medicare.
- A pharmacy refills a prescription that you no longer need without you knowing it. You don’t pick it up, but the pharmacy still bills Medicare.
- Someone offers to pay you for the use of your Medicare number to bill for prescription drugs or offers you cash or other payment to pick up prescriptions for you.
Read your Medicare statements to check for errors or suspicious charges.
If you have any concerns about your Medicare statements or medications, contact your local Senior Medicare Patrol (SMP). Your SMP can help and report the potential fraud to the correct authorities. Contact information for your local SMP is on the last page of this document.
SHINE is your local SHIP and SMP contact. Call us at 1-866-413-5337 or email us at shineinfo@aaaswfl.org.
All the information in this blog post was taken from the Part D Coverage Phases handout.
The Medicare Rights Center is the author of portions of the content in these materials but is not responsible for any content not authored by the Medicare Rights Center. This document was supported, in part, by grant numbers 90SATC0002 and 90MPRC0002 from the Administration for Community Living (ACL), Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.
Last Updated: February 28, 2024 by Leave a Comment
Medicare Minute: Part D Coverage Phases
The cost of your Medicare Part D-covered drugs may change throughout the year. If you notice that your drug prices have changed, it may be because you are in a different phase of Part D coverage. There are four different phases—or periods—of Part D coverage.
Deductible Period: Until you meet your Part D deductible, you are in the deductible period. During this time, you will pay the full negotiated price for your covered prescription drugs. While deductibles can vary from plan to plan, no plan’s deductible can be higher than $545 in 2024, and some plans have no deductible. You begin each new calendar year in the deductible.
Initial Coverage Period: After you meet your deductible, your plan will help pay for your covered prescription drugs. This is your initial coverage period. Your plan will pay some of the cost, and you will pay a copayment or coinsurance.
Coverage Gap: You enter the coverage gap when your total drug costs—including what you and your plan have paid for your drugs—reaches a certain limit. In 2024, that limit is $5,030. While in the coverage gap, you are responsible for 25% of the cost of your drugs. The coverage gap is also sometimes called the donut hole.
Catastrophic Coverage: In all Part D plans in 2024, you enter catastrophic coverage after you reach $8,000 in out-of-pocket costs for covered drugs. As of 2024, during this period, you owe no coinsurance or co-payments for the cost of your covered drugs for the remainder of the year. This puts a hard cap on your spending during the catastrophic phase of coverage. Before 2024, you paid 5% of the cost.
But what counts as an out-of-pocket cost? The out-of-pocket costs that help you reach catastrophic coverage include:
Costs that do not help you reach catastrophic coverage include monthly premiums, what your plan pays toward drug costs, the cost of non-covered drugs, the cost of covered drugs from pharmacies outside your plan’s network, and the 75% generic discount.
There are many types of pharmacy and prescription drug schemes. A few examples include:
Read your Medicare statements to check for errors or suspicious charges.
If you have any concerns about your Medicare statements or medications, contact your local Senior Medicare Patrol (SMP). Your SMP can help and report the potential fraud to the correct authorities. Contact information for your local SMP is on the last page of this document.
SHINE is your local SHIP and SMP contact. Call us at 1-866-413-5337 or email us at shineinfo@aaaswfl.org.
All the information in this blog post was taken from the Part D Coverage Phases handout.
The Medicare Rights Center is the author of portions of the content in these materials but is not responsible for any content not authored by the Medicare Rights Center. This document was supported, in part, by grant numbers 90SATC0002 and 90MPRC0002 from the Administration for Community Living (ACL), Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.
Posted: February 26, 2024 by Leave a Comment
Medicare Advantage Open Enrollment Period Ends March 31!
You can sign up for Medicare Part A and/or Medicare Part B during the General Enrollment Period if both apply:
This opportunity ends March 31, coverage will start the first day of the month after you enroll.
Medicare Advantage Open Enrollment Period (MA-OEP) is a single opportunity for someone currently enrolled in an advantage plan, that is not meeting their needs, to switch back to Original Medicare or another advantage plan. Deadline is March 31.
Call to speak with a SHINE Medicare Counselor at 866-413-5337.
Last Updated: February 26, 2024 by Leave a Comment
Four Signs That It’s a Scam
Protect yourself from fraud by learning how to identify scams. Here are four tactics scammers use:
If you suspect Medicare fraud, contact your local SHIP-SMP program by calling the Elder Helpline at 866-413-5337. Remember, your local SHIP program is known as SHINE (Serving Health Insurance Needs of Elders) in the state of Florida.
For more on the subject, visit How to Avoid a Scam (Federal Trade Commission Consumer Advice).
Posted: February 15, 2024 by Leave a Comment
It’s BINGO Time!
Area Agency on Aging for Southwest Florida (AAASWFL) will be partnering with the Center for Independent Living Gulf Coast and Florida Alliance for Assistive Services & Technology Southwest to host three BINGO events in March. These events are open to older adults (60+) and adults with disabilities (18+). BINGO will be called in both English and Spanish to accommodate all participants. Winners will receive prizes. Seating is limited to the first thirty registered individuals, so secure your spot now by registering at BINGO Registration.
When:
Friday, March 8, 2024
Wednesday, March 27, 2024
Friday, March 29, 2024
1:00 p.m. – 3:00 p.m.
WHERE: 2830 Winkler Avenue, Suite 112, Fort Myers, FL 33916
WHO: Free for older adults (60+) and adults with disabilities
Area Agency on Aging for Southwest Florida is a nonprofit organization serving Charlotte, Collier, DeSoto, Glades, Hendry, Lee and Sarasota counties. AAASWFL is the state’s designated Aging and Disability Resource Center for Southwest Florida. The organization is committed to connecting older adults and adults with disabilities to resources and assistance for living safely with independence and dignity. More information is available at https://www.aaaswfl.org or by calling the toll-free Helpline at 866-41-ELDER.
Posted: January 29, 2024 by Leave a Comment
How to Lower Your Part D Drug Costs
This year, people with Medicare may qualify for even more savings through the Extra Help program. This program helps some people pay their Medicare drug coverage (Part D) costs, like premiums, deductibles, coinsurance, and other costs. The program has expanded in 2024 and you may qualify.
In 2024, everyone who qualifies for Extra Help will pay $0 for their Medicare drug plan premium, $0 for their plan deductible, and a reduced amount for both generic and brand-name drugs! Your local SHINE program can help you see if you’re eligible or how to apply. To request help from SHINE, call the Helpline at 866-413-5337.
Last Updated: January 29, 2024 by Leave a Comment
Medicare Minute: Ending Care Appeals
If you are receiving care in a hospital or non-hospital setting and are told that your Medicare will no longer pay for your care, you have the right to a fast appeal if you feel that continued care is medically necessary. There are separate processes for hospital and non-hospital appeals. Non-hospital care includes care from a skilled nursing facility (SNF), Comprehensive Outpatient Rehabilitation Facility (CORF), hospice, or home health agency. You can appeal by following the instructions on the notices you receive.
Hospital Discharge Appeal
Non-Hospital Discharge
Ending Care Appeals
If the appeal to the BFCC-QIO is successful, your care will continue to be covered, including for the time you were appealing. If the BFCC-QIO decides that your care should end, you can file a second appeal within the timeframe on your BFCC-QIO denial notice.
There are five levels of appeal in total. The timing and agency involved depends on which type of care is ending and whether you have Original Medicare or a Medicare Advantage Plan.
Tips for filing Medicare appeals for care that is ending
• Follow instructions on the notices you receive.
• Stick to important deadlines.
• Keep original copies of information.
• Take thorough notes while appealing.
• Request a letter from your doctor or health care provider in support of your continued care to strengthen your appeal.
• Contact your local State Health Insurance Assistance Program (SHIP) for more guidance on appeals.
SNF Medicare Fraud, Errors, and Abuse
Medicare fraud can occur when a provider or facility bills for services you did not receive or were not medically necessary. Examples of potential skilled nursing facility (SNF) fraud:
SNF services for dates after you were released from the SNF
Contact your local Senior Medicare Patrol (SMP) to report Medicare fraud, errors, or abuse.
Call toll-free: 1-866-413-5337 | Email: shineinfo@aaaswfl.org
Ending Care Appeals available for download.
Posted: December 27, 2023 by Leave a Comment
Medicare Minute: What’s New in 2024?
With a new year comes changes to your Medicare costs and coverage. Download this timely handout for details on changes in hospital insurance, medical insurance and prescription drug coverage.
When can I change my coverage in 2024?
You may realize at some point in 2024 that you aren’t happy with your coverage. Many people may have to wait until the next Fall Open Enrollment Period (October 15 through December 7) to change their coverage. You may be eligible for other opportunities to change your coverage earlier in 2024, though:
If you have a Medicare Advantage Plan, contact your plan directly to learn about your 2024 costs.
“New” Medicare card schemes
Do you know what isn’t new this year? Your Medicare card.
Medicare beneficiaries are not receiving new cards this year, but scammers may try to convince you otherwise. For example, scammers may falsely tell you that Medicare is issuing new cards—perhaps a card that is plastic or metal, or a card that has a chip in it. The scammers may tell you that for them to send your new card, you need to verify your identity, which could include your Medicare number. This is an attempt to get your personal or financial information.
Here are some red flags to look for:
• Unsolicited calls from anyone claiming to be from Medicare
• Anyone needing your personal information so that they can send you an updated Medicare card
• Anyone saying your card is expiring, and they need to send you a new one or you will be charged a fine
• Anyone stating Medicare is issuing new cards and you need to verify your number
Have questions? Call our SHINE Medicare counselors at 1-866-413-5337 or email shineinfo@aaaswfl.org.
Last Updated: December 26, 2023 by Leave a Comment
Spotting the Signs of Elder Abuse
Abuse can happen to any older person. Abuse can happen at home, at a relative’s home, or in an eldercare facility. There are many types of abuse, including:
Keep on the look out for the following signs in older adults, that can include:
Isolated from friends and family
If you suspect elder abuse, neglect, or exploitation, speak with the older adult and then contact the Florida Abuse hotline at 1-800-96-ABUSE. This toll-free number is available 24 hours a day, every day. You can also find Elder Protection Programs from The Department of Elder Affairs for more information on the Florida Abuse hotline.
More information available on the National Institute on Aging’s website.
Infographic available for download.
Last Updated: December 15, 2023 by Leave a Comment
Collier County Transportation Disadvantaged Program Board is Looking for Volunteers
Representatives of the Area Agency on Aging for Southwest Florida are privileged to sit on the board for the Collier County Transportation Disadvantaged program. This board is in need of local Collier County residents to fill additional vacancies. They are looking for:
This is an important opportunity to provide advocacy for those who depend on the public transit fixed-route and para-transit options in Collier County.
There are four meetings held annually at the Collier County Government Center. Anyone interested can call Sarah Gualco, AAASWFL Director of Programs and Planning at (239-652-6926) for more info and to access the application.
Additional information about the local coordinating board (LCB):
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