In This Issue

	The Doughnut Hole By Miles Hurley While choosing a plan can be a frustrating experience, the most painful issue may well be from the Part D coverage gap, better known as the doughnut hole.
	If you answer yes to any of these questions, Hurley Elder Care Law can help
	Life Care Planning Goals
	The 2007 Hurley Elder Care Law Handbook of Resources

The Doughnut Hole - By Miles Hurley

	With the Medicare Part D enrollment period upon us again, this seems like a good topic to take a look in on. Medicare Part D is the prescription drug coverage program that was first put into effect earlier this year. While the idea is for every senior to have coverage for prescription drugs, there have been many misconceptions and understandings regarding the program. While choosing a plan can be a frustrating experience, the most painful issue may well be from the Part D coverage gap, better known as the doughnut hole.
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If you answer yes to any of these questions, Hurley Elder Care Law can help.

		Has the elder been diagnosed with a mentally or physically debilitating disorder such as Alzheimer’ s, Parkinson’s, ALS, stroke or a decline in functional capacity?
		Is the elder isolated due to the recent death of a spouse, or have family that either lives too far away or is too busy to provide adequate care?
		Is the elder soon to be discharged into a care facility or currently receiving in-home care?
		Does the elder have a variety of healthcare providers and need coordination and advocacy for quality care?
		Does the elder seem unusually concerned about costs of medication and services, indicating he or she may be having financial troubles?
		Does the elder have assets that fall between $50,000 and $400,000 – enough to finance a short stay in a care facility but not enough for an extended stay?
		Does the elder have a spouse whose financial needs must be considered in light of the elder’s medical condition?

Life Care Planning Goals

1. Meeting the elders’ immediate health care and long-term care needs.
2. Making sure the elder/family is making good health care and long-term care decisions.
3. Helping the elder/family sort through the maze of their long-term care options including residential options.
4. Identifying and accessing public benefits and resources to pay for care should the elder meet the qualifying criteria.
5. Help with asset management, including the burden of home ownership and personal property.
6. Providing the entire family the peace of mind that comes from knowing their loved one is monitored by a team that combines legal and financial expertise with specialized knowledge of the elders’ physical, mental and emotional health.
7. Ensuring the highest level of independence the elder can achieve, while ensuring safety.

The Doughnut Hole - By Miles Hurley

Continued from top of page Here is the problem with the doughnut hole: It is not possible for beneficiaries, their pharmacists or even their insurers to know in advance what drugs will really cost and when someone will fall into the hole. The reasons for this are all of the variables that are involved, which include: The co-pay, which varies, depending on the insurance company and the tier set for the drug; The generic price if the drug has a generic, even though that cost could exceed the brand name price in some plans; The discount price if there is a discount; The fee paid to the pharmacist, which is at least a couple of bucks; and The retail drug price paid by the insurer, which may change from day to day. Nationwide, there are more than 1,400 Part D plans, all offering different formularies and prices. Most Part D users take multiple drugs and the predictions for 2006 are that between 4 million to 7 million Part D enrollees (out of 20 million) will fall unwittingly into the doughnut hole and be obliged to pay full price for $2,850 in drugs before they can get out. (Kaiser Family Foundation). After reaching total combined spending of $5,100, Medicare will pay 95 percent of the subsequent drug bills during 2006. Most beneficiaries were unaware that the amount their insurer pays toward their drugs - not simply what they pay out of pocket themselves - counts against the initial benefit. There appears to be no good explanation for the doughnut hole, though congressional members who put the hole in stated that they wanted to save money and discourage people from buying drugs unnecessarily. Is there a way to close this gap? That remains to be seen at the current time, but with a Democratic Congress coming into session in 2007 and House Speaker Nancy Pelosi promising to allow the government to negotiate directly with the drug manufacturers, change may be on the horizon. The logic is that if middlemen were cut out and if CMS (Center for Medicare and Medicaid Services) were permitted to use its buying power to bargain for lower prices from the drug companies, the savings could cover the hole. Additionally, if the administration of the drug benefit was placed under Medicare rather than the hundreds of different plans currently offered, the coverage gap could be eliminated. All of these factors go in to figuring out why no one seems to be able to give beneficiaries the right answers to their Part D questions. Also, since prices change so often a beneficiary can't know when he or she will fall into the hole. Nor can beneficiaries find out what their drugs will cost this month or compare what they pay with the prices of drugs in other plans. It does appear that as Part D is currently administered, there is no oversight on pricing by either the administration or by Congress. Even the Members of Congress have been unable to penetrate the mysteries of drug pricing, as the manufacturers consider proprietary information. As for the Part D beneficiaries, the doughnut hole will grow wider every year as drug prices increase. One estimate is that the out-of-pocket costs will rise from the current $5,100 to $5,500 by 2010. Finally, per the Kaiser Daily News, the open enrollment period begins Wednesday for the 2007 Medicare prescription drug benefit. During the open enrollment period, which ends Dec. 31, beneficiaries can switch plans or sign up for a plan for the first time. Many beneficiaries might "want to [change plans] because prices have changed, with some of the most popular plans charging much higher premiums for 2007."The average monthly premium for the standard drug benefit for 2007 will be $24, about the same as in 2006, although "many plans provide additional benefits for an extra premium," the New York Times reports. The average monthly premium for stand-alone drug plans will increase 10% for 2007, while the average monthly premiums for drug coverage through Medicare managed care plans will decrease 35%, the Times reports. The majority of plans include a gap in coverage during the so-called "doughnut hole" coverage gap, although some cover generic drugs during the gap and a few also cover brand-name medications, according to the Times. Deane Beebe of the Medicare Rights Center said, "Beneficiaries tell us this was a helpful benefit for six or eight months, until they fell into the coverage gap."She added, "In 11 states, we cannot find any free-standing drug plan that provides coverage for brand-name drugs in the gap." However, HHS Secretary Mike Leavitt said, "The program is working. People are happy." Several recent surveys have found that about three-quarters of beneficiaries enrolled in the drug benefit are satisfied with their coverage (Pear, New York Times, 11/15). If you would like to hear a webcast on this topic from the Kaiser network please follow this link: Ask the Experts: Open Enrollment for Medicare Part D