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David Sayen: What’s New in Medicare for 2011?

Health-care reform law brings changes to Medicare Part D and preventive services

There are a number of improvements to Medicare this year, thanks to the new Patient Protection and Affordable Care Act.

David Sayen
David Sayen

One big change is that people with Medicare Part D, the prescription drug program, will see a 50 percent discount on prescription drugs if they’re in the so-called donut hole.

The donut hole is the point at which Part D coverage temporarily stops, and you pay all of your drug costs out of pocket. You enter this gap when your total drug costs for the year — meaning all costs paid by you and your insurance company — hit a certain level. The threshold for this year is $2,840.

Once you’re in the hole, you pay all of your drug costs. When your out-of-pocket spending for the year hits $4,550, you get out of the hole. After that, you have catastrophic coverage, and you’ll pay only about 5 percent of your drug costs.

So how does the discount work?

In 2010, people who went in the donut hole got a one-time, tax-free check for $250. This year, instead of a check, people in the hole will get a 50 percent discount on almost all brand-name prescription drugs and a 7 percent discount on generic drugs. These discounts can produce big savings for people who need expensive medications. The discounts will gradually increase until the hole is closed in 2020.

A caveat: People who have drug coverage through a retiree plan or people who have the Part D low-income subsidy are not eligible for a discount.

The health law also eliminated most co-pays and deductibles for a range of Medicare preventive health services. The idea was to reduce out-of-pocket expenses so more people with Medicare will take advantage of these services, which can keep you healthy and detect disease when it’s in the earliest, most treatable stages.

Among the preventive services Medicare covers are:

» Screenings for breast, prostate, colon and cervical cancer

» Tests for glaucoma, diabetes and cardiovascular problems that can lead to heart attack or stroke

» HIV screening, hepatitis B shots, and annual flu and pneumonia shots

People with Medicare also can get counseling from their doctor or other qualified health professional to help them stop smoking, and to help them manage their diabetes on their own.

Click here for a complete list of Medicare-covered preventive health benefits. In addition, people with Medicare now can get a wellness exam every year, with no out-of-pocket costs. This exam lets you and your doctor put together a prevention plan just for you, based on current health and risk factors.

When you first sign up for Medicare, you’re also eligible for a one-time “Welcome to Medicare” physical exam. Thanks to the Affordable Care Act, this exam no longer has a deductible or a 20 percent co-pay.

One last point: Although Medicare’s annual open enrollment period closed Dec. 31, you can still make some limited changes to your health coverage until Feb. 14.

If you’re in a Medicare Advantage plan, you can switch to Original Medicare during this period. If you make that change, you also have until Feb. 14 to sign up for a Part D prescription drug plan.

However, you can’t do the reverse — switch from Original Medicare to Medicare Advantage during this period. You also can’t switch from one Medicare Advantage plan to another, or from one Part D plan to another.

— David Sayen is Medicare’s regional administrator for Arizona, California, Hawaii, Nevada and the Pacific Trust Territories.

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