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Medicare Coverage Gap Vexes Patients, Survey Says
By Marley Seaman, Associated Press
November 18, 2008
A survey taken of Medicare Part D recipients revealed a gap in knowledge about their policy benefits. Many policyholders do not understand the “coverage gap” during which beneficiaries are responsible for covering the full cost of their prescription medications. Once a beneficiary’s cost of drugs reach a limit, they are expected to pay up to a certain amount before the coverage can resume. Many senior patients are unaware of the spending that goes toward covering the “coverage gap.” Many patients in the gap require expensive medications to treat chronic disease. This feature of the Medicare Part D is unfortunate and unfair for seniors who have to spend an exorbitant amount on medications and some may not have the financial resources.
A survey of Medicare Part D enrollees showed that most of them do not fully understand the coverage gap, or "doughnut hole," under which they must pay full cost for their prescription drugs, Medco Health Solutions said Monday.
The survey showed that out of 1,000 chosen survey respondents, 62 percent said they did not fully understand the concept, and 28 percent said they didn't know what it was or didn't understand it at all. More than two-thirds of respondents in the coverage gap were not able to identify the spending that counts toward the gap.
For the year 2008, once a patient's drug costs reach $2,510, they must pay full cost for their medications on their own until their spending reaches $3,850. At that point, their coverage resumes.
The size and limits of the gap increase each year, but according to the survey, many patients don't know how that spending is calculated: the amount patients pay on their own is counted toward the gap, but so is the spending by their health plan.
Once the patient is in the gap, he or she is responsible for all spending on drugs covered by Medicare Part D. In 2008, coverage resumes after the patient has spent $3,850 out of pocket.
"At this point the majority of members do know that there's a gap in their coverage but they don't understand how they arrive there, and there's a few different points of confusion there," said Woody Eisenberg, chief medical officer at Medco. "People know there's a gap but there's still lots of confusion about how they get there."
He said the gap in coverage is an "unusual" feature that was expected to cause confusion after the Medicare Part D benefit went into effect in 2006. While Eisenberg feels the Center for Medicare and Medicaid Services has done a fair job of explaining the gap, individual patients don't always know how it applies to them specifically.
In the survey, 39 percent of patients who were in the gap said they received enough information about the gap and felt fully aware of it. But 26 percent said they received no information, and 27 percent said they found the materials about the gap confusing. The rest received the details but didn't fully review them.
More than three-quarters of the patients who had already reached the doughnut hole were being treated for at least one chronic ailment.
Direct Analytics conducted the random telephone survey with funding from Medco, a pharmacy benefits manager based in Franklin Lakes, N.J.
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