Millions Of People with Medicare Have Reached “Catastrophic” Part D Coverage

 

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Millions Of People with Medicare Have Reached “Catastrophic” Part D Coverage

• By Casey Schwarz
• July 29, 2021

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Medicare Part D, which covers outpatient prescription drugs for people with Medicare, has four phases of coverage: the deductible, when the beneficiary pays the full cost of the medication; the initial coverage period, when the plan pays for most of the cost of the medication and the beneficiary pays a copay or coinsurance; the coverage gap, also known as the “donut hole,” where the beneficiary pays 25% of the cost while the government, drug manufacturers, and the plan pay the rest; and finally, the catastrophic coverage phase, where beneficiaries usually pay 5% of the cost and plan pays for the remainder.

In 2021, beneficiaries will reach catastrophic coverage phase when they have spent $6,550. But because there is no hard cap on beneficiary out-of-pocket spending in Part D, those who take high-cost medications may pay thousands of dollars above the catastrophic threshold—5% of a $10,000 drug can add up fast.

This week, the Kaiser Family Foundation (KFF) released a report showing that for millions of older adults and people with disabilities, this scenario is all too real. Over the five-year period from 2015-2019, 2.7 million enrollees had at least one year with spending above the catastrophic limit, and over the ten-year period from 2010-2019, 3.6 million did. Reaching catastrophic coverage can come with enormous expense. In 2019 alone, nearly 1.5 million Part D enrollees spent $1.8 billion on prescription medications after exceeding the threshold.

According to KFF, the number of beneficiaries who reach the catastrophic coverage phase has increased annually since 2010. While this is likely attributable to several factors, including higher drug prices and growth in the total number of Part D enrollees, it is an alarming trend that warrants immediate policymaker intervention.

Medicare Rights supports legislation to establish a hard cap on beneficiary out-of-pocket costs, including as outlined in H.R. 3, the Elijah E. Cummings Lower Drug Costs Now Act. This long overdue change would better protect access to needed medications and strengthen the health and financial security of older adults and people with disabilities.

Join Medicare Rights in urging Congress to take swift action on this and other needed Medicare improvements. Learn more and weigh in today. 

Read the KFF report, Millions of Medicare Part D Enrollees Have Had Out-of-Pocket Drug Spending Above the Catastrophic Threshold Over Time.

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WHAT HOME HEALTH SERVICES DOES MEDICARE COVER?

 

What home health services does Medicare cover? Dear Marci, I need to start physical therapy, but it is very difficult for me to leave my home due to my injury. What home health services does Medicare cover? -Ada (Rockville, MD)   Dear Ada, Home health care includes a wide range of health and social services delivered in your home to treat illness or injury. If you qualify for the home health benefit, Medicare covers the following: Skilled nursing services, such as injections, tube feedings, catheter changes, observation and assessment of your condition, and wound care Provided up to seven days per week for generally no more than eight hours per day and 28 hours per week. In some circumstances, Medicare can cover up to 35 hours per week. Skilled therapy services, such as physical therapy, speech language pathology, and occupational therapy Note: You cannot qualify for Medicare home health coverage if you only need occupational therapy. However, if you qualify for home health care on another basis, you can also get occupational therapy. When your other home health needs end, you can continue receiving Medicare-covered occupational therapy under the home health benefit if you need it. Home health aide, who provides personal care services like bathing, toileting, and dressing Note: Medicare pays in full for an aide if you required skilled care. Medicare will not pay for an aide if you only require personal care and do not need skilled care. Medical social services, such as counseling or help finding resources in your community Medical social services are ordered by your doctor to help with social and emotional concerns you have related to your illness. Medical supplies, such as wound dressings and catheters Durable medical equipment (DME), such as wheelchairs and walkers There are certain requirements one must meet to be eligible for the home health benefit. For example, an individual must be considered homebound and have a plan of care approved by their doctor. Do note, however, that during the current coronavirus public health emergency, some of these requirements have been changed to allow for greater access to home health care. It is also important to know that your home health care is covered by Medicare even if your condition is chronic or if you are not showing signs of improvement. Speak with your doctor to begin home health care. If you have Original Medicare, call 1-800-MEDICARE or visit www.medicare.gov/care-compare to find a list of Medicare-certified home health agencies (HHAs). If you have a Medicare Advantage Plan, you should contact the plan directly for a list of HHAs in your plan’s network. -Marci       The month of March is National Brain Injury Awareness Month, which provides a time to bring attention to the prevention of traumatic brain injury (TBI). According to the CDC, falls are the leading cause of TBI. To prevent falls, follow these tips from the CDC: Talk to your doctor Ask your provider to evaluate your risk for falling, to review your medicines, and to discuss taking vitamin D supplements Do strength and balance exercises Tai Chi is a good example of exercise that improves balance. Click here to find instructors near you or here for three Tai Chi moves for beginners. Have your eyes checked Make your home safer Get rid of things you could trip over, like throw rugs or clutter Add grab bars inside and outside your tub or shower and next to the toilet Put railings on both sides of stairs Make sure your home has lots of light by adding more or brighter bulbs       Upcoming webinar: How Medicare Works with Job-Based Insurance Job-based insurance is insurance offered by an employer or union for current employees and family members. This coverage can allow for a delay in Medicare enrollment, but it may be wise to enroll in Medicare depending on whether the job-based insurance pays primary or secondary. Date: Thursday, March 25 Time: 3:00 – 4:00 PM Eastern Time Fee: $40 per person for the live webinar and recording, or $30 per person for the recording only. Experts from the Medicare Rights Center will answer your questions about the following topics: The difference between primary and secondary insurance  Medicare and Employer Group Health Plans  How Medicare and retiree insurance work together  How Medicare works with COBRA  The Part B Special Enrollment Period (SEP)  Medicare enrollment outside of set enrollment periods  Register for this webinar on Medicare Interactive.