Mind the Gap: What is the Medicare Part D Coverage Gap?

If you visit the UK, you might be tempted to take a ride on the London Underground, the city’s sprawling train system. If you do, you might notice lots of red and blue signs posted everywhere, with a very charming, very British message in bold font: “Mind the gap.”

“Mind the gap” signs have been parodied and meme-d all over the internet, and you’ll find modified versions of this message in train stations all over the world. These signs are a reminder to commuters to watch their step when getting on and off of a train car.

But whether you’re queuing up for the “Tube” or not, we think “mind the gap” is a great phrase to keep in mind  — even for your Medicare prescription drug coverage!

What is the Medicare Part D Coverage Gap?

Also known as the donut hole, the Medicare Part D coverage gap refers to a temporary limit on how much Medicare drug plans will pay for certain medications. The gap is triggered when a Medicare beneficiary and their drug plan pay a specified amount on covered prescription drugs within a set timeframe.

In other words, after you and your drug plan have spent a certain amount of money on covered drugs, you enter the gap. During this time, you will be required to pay all of your out-of-pocket costs for your drugs, up to a certain yearly limit. Once you hit your out-of-pocket limit, coverage kicks back in, and the gap closes again. At this point, beneficiaries return to paying a smaller coinsurance or copayment on their covered medications for the rest of the calendar year.

How Do You Get Out of the Coverage Gap?

While you’re in the coverage gap, certain out-of-pocket expenses will count toward your yearly limit, including:

  • payments toward your yearly deductible
  • coinsurance
  • copayments

Your premium does not count toward getting you out of the gap, nor will any payments you make for drugs not covered under your plan.

Can You Avoid the Coverage Gap?

When it comes to Medicare prescription drug coverage, is it as easy to “mind the gap” as it is on the subway?

As a matter of fact, there are some steps that Medicare beneficiaries take to help avoid the coverage gap. So, what can you do to stay away from the donut hole? One option is to take steps to lower the amount that you pay for your prescriptions, so that you never hit the threshold that sends you into the gap in the first place.

For example, many Medicare recipients see advantages to purchasing generic versions of their prescription drugs, whenever possible. Generic drugs must be FDA-approved, and be proven to have the same effect as their name brand counterparts. For the sake of keeping your costs low, it may be worth speaking to a healthcare provider about switching your prescriptions to generics, if possible.

Other ways to minimize your costs, and avoid the gap, may include:

  • Comparison shop at local pharmacies; some may offer your prescriptions at a lower cost
  • Determine if your plan offers preferred pharmacies. When available, preferred pharmacies tend to have lower copayments/coinsurance rates than standard pharmacies.
  • If your prescription plan allows you to, consider purchasing your medications at a discount by ordering your supply in advance, through the mail.
  • Inquire about assistance with drug costs from private, state, or federal programs
  • Seek out a new drug plan or coverage options

A few more things to keep in mind? People with limited incomes who enroll in Medicare Extra Help do not face the coverage gap. And, under current law, the coverage gap is shrinking over time, and may be closed within a few years, assuming that there aren’t any sweeping changes between now and then.

You Have Options When It Comes to Medicare!

According to a recent survey, nearly half of Medicare beneficiaries say they have never shopped around to find the best coverage for them, and 41 percent say they do not think they would save any money by shopping around. And this is despite the fact that almost a third say that they are “worried about their ability to pay out-of-pocket health-care costs.”

It doesn’t have to be this way!

If you’re worried about Medicare costs — including prescription drug costs before, during, or after the coverage gap — there are options out there to help. Working with a health insurance consultant can help you save hundreds or thousands of dollars every year, simply by helping you find the drug coverage plan that will work best for your unique needs.

In many cases, Medicare beneficiaries can also help manage their health costs by opting for Medicare supplement insurance. Also called Medigap plans, these are private health insurance plans designed to help you pay for the healthcare costs that original Medicare does not cover, like copayments, coinsurance, and deductibles.

In addition to giving you greater flexibility when it comes to your coverage, these supplemental plans can help recipients save thousands of dollars in out-of-pocket medical expenses.

There’s no limit to what you may be able to put those savings toward — from keeping your lifestyle intact for years; to settling into a more comfortable retirement; to finally going out and taking that ultimate trip (maybe even to London?).

The Benefits of Working with a Broker

Looking to “mind the gap” is one thing, and it’s a big one, but there are also many other moving parts when it comes to Medicare. Taking it all on your own can be overwhelming.

That’s where the Enrollment Specialists can help! Led by our founder and principal consultant, Matt Peebles, the Enrollment Specialists are here to help demystify Medicare — giving you greater peace of mind, and more money in your pockets!

Matt doesn’t believe in cookie-cutter care, and he’ll work closely with you to customize the insurance policy that will work best for your needs, making sure your costs are minimized and your coverage it at its peak.

And with Matt on your side, you won’t need to bother with the hassles of call centers, online chat rooms, or canned responses! You’ll always be able to get a hold of this health insurance superhero right when you need him most.

Attention to detail, stellar customer service, and a deep knowledge about all things Medicare? There’s a reason why Matt is recognized in the top 1 percent nationally of all health insurance producers, with hundreds of happy clients around the country!

Want to find out when you may hit a gap in your current Medicare plan? Ready to say, “I Got A Guy!” for all things Medicare? Don’t hesitate to get in touch today!

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