Review the following information access and read the article

Review the following information, access and read the article under the reference, and answer these questions:

Joan, a Medicare beneficiary, has Crohn’s disease with an ileostomy, cardiac disease with four stents, chronic interstitial cystitis, diabetes, generalized osteoarthritis with cervical and lumbar spondylosis, and is status post unilateral knee replacement.

In August, Joan entered the doughnut hole. Why? How can Joan get out of the doughnut hole?

According to the article by Neuman and Cubanski, is Joan’s case unusual?

According to the article by Neuman and Cubanski, is Joan likely to get out of the doughnut hole?

ARTICLE:

The Medicare Prescription Drug Coverage (Medicare Part D) is similar to the benefits for prescription drugs of many voluntary healthcare insurance companies. For Medicare beneficiaries, Medicare Part D is a plan that provides coverage for prescription drugs. Medicare Part D’s similarities to voluntary healthcare insurance plans include:

Medicare beneficiaries must pay a monthly premium to purchase this coverage. The national base beneficiary premium is about $32

Each calendar year begins a new benefit period

Only medically necessary drugs are covered

Cost-sharing (out-of-pocket) features, such as deductibles, copayment or coinsurance, formularies, tiered coverage, and a coverage gap (similar to a benefit cap)

Medicare Part D was effective January 1, 2006. Medicare Part D is administered by private healthcare insurance plans. The Centers for Medicare and Medicaid Services allows private healthcare insurance companies to offer various combinations of benefits within a set of requirements. Components that can vary among private healthcare insurance companies are premiums, deductibles, copayments or coinsurance, formularies, and tiers. Two set parameters are the thresholds for the coverage gap (doughnut or donut hole) and for the catastrophic coverage.

Thresholds for the coverage gap and the catastrophic coverage are unique elements of Medicare Part D. The coverage gap (doughnut or donut hole) is an amount of out-of-pocket costs for the Medicare beneficiaries based on dollar thresholds. Between the dollar thresholds, Medicare Part D pays none of the cost of prescriptions and the Medicare beneficiary pays all of the cost of prescriptions. Medicare Part D begins paying again after the beneficiary reaches the threshold of the catastrophic coverage. To reach the catastrophic coverage, Medicare beneficiaries must pay true out-of-pocket (TrOOP) costs (deductible, coinsurance or copayment, and prescription costs, excluding monthly premiums) and must continue to pay their monthly premium.

Table S3.1. Sample Initial Medicare Part D Benefits

Monthly Premium

Annual Deductible

Initial Coverage

Coverage Gap

Catastrophic Coverage and Reduced Copayment or Coinsurance Resumes

Copayment

Per Each Filled Prescription

Coinsurance

Per Each Filled Prescription

$26

$250

$5 Tier 1 (Generic)

$25 Tier 2 (Preferred)

$55 Tier 3

(Non-preferred)

$100 Tier 4 (Specialty)

25% Tiers 1, 2, and 3

33% Tier 4 (Specialty)

$2,250 to $3,600

>$3,601

$2 copayment per each filled prescription Tiers 1 and 2

$5 copayment per each filled prescription Tiers 3 and 4

or

2% coinsurance per each filled prescription Tiers 1 and 2

5% coinsurance per each filled prescription Tiers 3 and 4

Table S3.2. Sample Current Medicare Part D Benefits

Monthly Premium

Annual Deductible

Initial Coverage

Coverage Gap

Catastrophic Coverage and Reduced Copayment or Coinsurance Resumes

Copayment Per Each Filled Prescription

Coinsurance

Per Each Filled Prescription

$40

$310

$10 Tier 1 (Generic)

$35 Tier 2 (Preferred)

$75 Tier 3

(Non-preferred)

$120 Tier 4 (Specialty)

25% Tiers 1, 2, and 3

33% Tier 4 (Specialty)

$2,831 to $4,550

>$4,551

$2.50 copayment per each filled prescription Tiers 1 and 2

$6.00 copayment per each filled prescription Tiers 3 and 4

or

2% coinsurance per each filled prescription Tiers 1 and 2

5% coinsurance per each filled prescription Tiers 3 and 4

Reference

Neuman, P., and J. Cubanski. 2009 (July 23). Medicare Part D update--lessons learned and unfinished business. New England Journal of Medicine 361(4):406-414. http://www.nejm.org/doi/full/10.1056/NEJMhpr0809949

Monthly Premium	Annual Deductible	Initial Coverage	Coverage Gap	Catastrophic Coverage and Reduced Copayment or Coinsurance Resumes
Copayment Per Each Filled Prescription	Coinsurance Per Each Filled Prescription
$26	$250	$5 Tier 1 (Generic) $25 Tier 2 (Preferred) $55 Tier 3 (Non-preferred) $100 Tier 4 (Specialty)	25% Tiers 1, 2, and 3 33% Tier 4 (Specialty)	$2,250 to $3,600	>$3,601 $2 copayment per each filled prescription Tiers 1 and 2 $5 copayment per each filled prescription Tiers 3 and 4 or 2% coinsurance per each filled prescription Tiers 1 and 2 5% coinsurance per each filled prescription Tiers 3 and 4

Solution

1) Yes, because he/she affected so much of disease. Having possibilities getting out of the doughnut hole

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2) yes, Joan’s case considered to be a unusual case, because the case having cardiac problem, diabetes, and knee replacement. Insurance covers plan includes any one of the diseases are affected, it can cover. So this case seems to be unusual.

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3) According to article by Neuman and Cubanski, Joan likely to get out of the doughnut hole, because

Current Medicare Part D Benefits is higher than initial medicare, it rates are higher in the sides of Initial Coverage,

Coverage Gap, Catastrophic Coverage and Reduced Copayment or Coinsurance Resumes.

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