Health Reform: CMS Outlines Doughnut Hole Discount Program
The phaseout of the Medicare Part D coverage gap begins in 2011. Starting next year, people who hit the coverage gap or “doughnut hole” in the Medicare drug benefit will receive a 50 percent discount at the pharmacy—without having to send in receipts or request a refund—according to draft guidance implementing the recently passed health reform law.
The guidelines from the Centers for Medicare and Medicaid Services (CMS) also state that the insurance companies offering Part D plans will inform pharmacies through their electronic claims systems when consumers are eligible for the discount, although the discounts will come from drug manufacturers.
State pharmaceutical assistance programs (SPAP- such as Massachusetts’ Prescription Advantage program) that provide coverage through the doughnut hole will also benefit from the discounts, while consumers enrolled in these programs will continue to pay the copays charged by their SPAP. Consumers enrolled in Part D plans offered by their employers, which often provide coverage through the doughnut hole, will not be eligible for the discount, according to CMS’s proposed guidance.
The phaseout will be complete in 2020, at which time consumers in the coverage gap will pay 25 percent for their brand-name and generic drugs—the same share they pay before reaching the gap.
The guidance was open for public comment until May 14, 2010, and may be revised.
-From “ Filling in the Gaps”, e-mail from Medicare Watch, The Medicare Rights Center, May 06, 2010, and “Averting the Cuts”, e-mail from Medicare Watch, The Medicare Rights Center, May 20, 2010.
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