Tag Archives: Affordable Care Act Donut Hole

Affordable Care Act and Medicare

Many consumers have questions about Medicare and Medigap; and how the two programs are impacted or not impacted by the Obama Health Care Act. It is important to know how all three programs are related to each other.


Medicare is not a part of Affordable Care Act. You will not lose Medicare coverage or parts of coverage due to Affordable Care Act. In some cases, at state marketplaces, the applications for the two programs are a simultaneous action. However, if you are happy with your Medicare, or any other health care plan you have, you can remain a participant of that program if qualified. You do not have to replace your Medicare with a marketplace health care. You will still receive your Medicare and not have to make any changes.

It is actually against the law for a state-run marketplace to try to sell you or to sell you a marketplace plan if you currently have a Part A or Part B Medicare plan. Part A Medicare covers:

• Nursing facility care
• Hospital services
• Nursing home care
• Home health services
• Hospice

A Part B Medicare Plan covers:

• Ambulance services
• Clinical research
• Medical equipped deemed durable
• Mental health inpatient
• Mental health outpatient
• Mental health part hospitalization
• Second opinion prior to surgery
• Some outpatient prescription drugs

Affordable Care Act is advertising that it has made some Medicare reforms for the positive. But that those new changes would not negatively impact those with Medicare health coverage even though the cuts are expected to be over 715 billion dollars in cost. These cuts are designed to improve and modify health care benefits for seniors.

If you have Medicare Part A or Medicare Part C (sometimes called Medicare Advantage) you are considered to all ready have the Essential coverage required under Affordable Care Act. Medicare Advantage replaces the standard Original Medicare providing better benefits and health care coverage options, but at a higher upfront expense than the old Original Medicare plan. The upfront expenses are then able to be offset by the greater cost coverage and the more expansive benefits that Medicare Advantage now provides. Since Medicare Part A and Medicare Part B are a piece of Medicare Advantage, and are required to offer at least the benefits offered by Original Medicare, you won’t receive less health care benefits than you would from the Original Medicare.

However, do note that even though the Affordable Care Act does not affect senior’s premiums, the health care premiums for high-income seniors who make more household income than $85,000 or couples with incomes higher than $170,000 will increase. These premiums actually would have increased with or without the Affordable Care Act.

Medicare Reform

The Affordable Care Act Medicare Reform includes:
• Closing the hole that made some Seniors unable to pay for prescriptions (sometime called the “donut hole”)
• In 2012, seniors got a 50% discount when purchasing name brand drugs
• In 2012 they got a 14% discount when purchasing generic drugs (under Medicare Part D)
• By 2020 the coverage will increase and the hole will close with co-payments only
• Seniors will get better access to wellness visit, prevention program, screenings for cancer, flu shots, and other important vaccines
• Affordable Care Act does not cut Medicare Advantage benefits
• It reduces payments to Medicare Advantage
• Medicare is protected for many years to come with the trust extended to 2020
• Part B premiums will not increase next year
• More than 340 Accountable Care Organizations have been added to the network


A health care insurance supplement that helps the consumer pay for things Medicare will not pay for is called Medigap. It is not a piece of Affordable Care Act. A private company, not the state marketplace, sells it. It can help lower income and aid elderly people on a fixed budget in meeting their insurance needs.

Information on this supplement can be found at http://www.medicare.gov/supplement-other-insurance/. You can shop around for this supplement or talk to your insurance agent for details, also. Remember, you have to be familiar with all your policy covers or do not cover. You also need to know your rights as far as insurance is concerned. This can be complicated when you have more than one health care policy.

The bottom line is that your Medigap can cover the services that your Original Medicare will not take care of for you. For example, Medicare won’t cover you if you are traveling out of the country and have medical needs. Just like Medicare, Medigap is not a part of Affordable Care Act. You should know the following Medigap facts and details:

1. To sign up for Medigap, you must be enrolled in a Medicare Part A or Medicare Part B plans.
2. To sign up for Medigap, you have to leave the Medicare Advantage Plan before the Medigap will begin to go into effect.
3. You will remit a monthly premium to the insurance company who sold you the Medigap plan, as well as remit payment for your Medicare Part B premium.
4. Medigap cannot be shared among spouses or family. An individual plan must be purchased for each person.
5. A Medigap policy can be purchased from a licensed insurance agent.
6. A Medigap plan is renewable. This remains true even if you have health complications. However, as long as payments are made by due dates, the policy cannot be cancelled due tot hose medical problems.
7. Remember, if you have a Medicare Medical Savings account, it is illegal for a company to try, or to sell you a Medigap policy.
Knowing what Medicare and Medigap insurance policies you need, and how those policies relate to Affordable Care Act is important. If you get confused in the application process, you can visit your local social security office, call your insurance agent, or call 1-800-772-1213. TTY users should call 1-800-325-0778.