There are several improvements to Medicare coverage beginning in 2019.
The “Donut hole” is going away
The “Donut hole” refers to the Medicare Part D benefit that requires enrollees with high prescription costs to pay all costs out-of-pocket for his or her medication after they reach a certain level of spending. After the out-of-pocket spending reaches a second threshold, the beneficiary will enter a “catastrophic coverage” period and pay substantially less. This gap in coverage is commonly referred to as the “donut hole.”
Under the Affordable Care Act (ACA), the donut hole was scheduled to close in 2020, but the spending bill Congress passed in March of 2018 will close the donut hole for brand-name drugs in 2019. The gap will close for generic drugs in 2020. This is great news for those individuals who have high brand-name prescription medication costs each year.
Therapy cap eliminated
For two decades, payments for therapy treatments have been capped. The 2018 cap amount for physical therapy and speech-language pathology services combined was $2,010 per calendar year. The 2018 cap amount for occupational therapy services was $2,010 per calendar year.
In February of 2018, the Bipartisan Budget Act of 2018 was signed into law to eliminate the limits on how much Medicare pays for therapy services in a calendar year.
Expanded telemedicine
Medicare is broadening the availability of telehealth programs that allow patients to confer with a doctor or nurse via internet or telephone. Beginning in 2019, Medicare will begin covering telehealth services for:
Tele-stroke: Previously to this change, Medicare covered telehealth services for stroke patients located in rural or non-urban areas only. Under the new law, patients that arrive at a hospital with acute symptoms may receive a telehealth consultation without regard to their location.
ESRD Patients: End-stage renal disease patients on home dialysis will be able to receive their monthly clinical assessments at home.
This is a significant benefit not only for the recipient of these benefits, but for the caregivers responsible for providing transportation for the beneficiary to his or her doctor’s appointments.
Lifestyle support
Medicare Advantage plans in 2019 will have the option to cover meals delivered to the home, transportation to doctor’s appointments and provide safety features in the home such as bathroom grab bars and ramps for wheelchairs. A medical provider will have to recommend these in order to be covered.
In-home help
Medicare Advantage plans will have the option to pay for assistance from home health aides. This benefit can help beneficiaries with daily activities including personal care, dressing, and eating. The range of benefits will be much broader beginning in 2019, expanding from the traditional requirement that Medicare services be primarily health related.
“Test drive” window to try an Advantage plan has expanded
New regulations will let people try an Advantage plan for up to three months and, if they would like to change, they can switch to another Medicare Advantage plan or choose to enroll in original Medicare. Before this change, an individual had until February 14th to drop out of it and switch to the traditional Medicare and a Part D plan and did not have the option to change to another Medicare Advantage plan.
Better information
Medicare is updating the handbook it sends to beneficiaries every fall. It will now include checklists and flowcharts to make it easier to decide on coverage. The online Medicare Plan Finder tool will be more user friendly and the “coverage wizard” can help individuals compare out-of-pocket costs and coverage options between original Medicare and Medicare Advantage.
Carol Chaudet
(Updated 1/2/2019)