what is the donut hole?

The donut hole is much less scary than it used to be. The drug company and insurance company pays the majority still. My co-pay is 25% and for many of my drugs (old and generic) my copay will be $2.50. A few will be more.

The infamous Rx coverage gap. The donut hole is when you reach 5030 dollars in drug expenditures (total of your copay and insurance payments) Medicare no longer covers until you pay X dollars out of pocket. But reforms have made it less onerous.

Of the total cost of the drug, the manufacturer pays 70% to discount the price for you. Then your plan pays 5% of the cost. Together, the manufacturer and plan cover 75% of the cost. You pay 25% of the cost of the drug.

it's such a pointlessly convoluted system.

the first biologic, I qualified for free meds from the manufacturer (technically from their "foundation"). when it ultimately didn't work, my second drug is administered via infusion.

as a result of someone else putting it in me, the entire thing falls under part B instead of part D.

PArt B is so much better than Part D.

they spent a year building a new and improved infusion clinic, which opened in March of last year. it was a disaster, they totally screwed up the billing.

a few days before my next infusion I logged into MyChart and saw that they hadn't processed the claim for the first infusion at the new place. but they had also jacked up the price almost 5x what was charged at the old clinic.

hours on the phone, I was basically told don't worry, wait and see what Medicare does. I canceled that second infusion appointment because I didn't want to risk medical bankruptcy.

I went six+ months without treatment before caving and going for an infusion. that March 2023 claim is still not processed.

The "good" news is that my out of pocket copay is in the same ballpark as it was before for newer infusions. but they are still managing to soak Medicare for over 10k extra per dose. it feels like fraud.

oh the fun part was when I found out in the middle of all of this is that it wasn't just me. I think it was in June that my rheumatologist told me that all claims to Medicare were getting rejected, and the clinic was missing millions in reimbursement.

Damn. If they don't submit the claim in time for insurance to pay it, that's on them, by the way. I had home health for 10 months after I got out of the hospital in 2011. Every day at first, then dropping down as I got better to 3 to 2 to 1 per week. It was thousands of dollars and they sent the bill all at once 3 years after. I only knew because I got

my quarterly explanation of benefits that noted the bill and that it was denied and the reason being submitted too late. Patient Responsibility 0

yeah, I think Medicare has a 1 year limit? This was submitted, rejected, resubmitted, rejected, appealed... idk. I basically had a direct number for someone in billing I could call, who was friendly and helpful at first but got tired of dealing with it.

I could tell from what she said that she had to drill down into a sub-page of their system to see the denial state, and apparently nobody had been doing that? like nobody had seen the claims actually being denied??

I just kept getting told that the Director of the Department was personally looking into my case. But I would call back weeks later and billing lady would go and find a new denial status.

Uwmed is basically rotting from the core.

When I login to MyChart, I have a sidebar with "my care team". and all the names listed except for the first are missing profile pictures, because all of those people have already left. Today I had my final appointment with my primary doc, she's moving to Boston. I'll have no profile pics left.

(emotional goodbye doc appointment sponsored this rambling tangent)