Jean Wright fell into the 'doughnut hole' of the Medicare prescription drug program in late May, receiving just five months of insurance coverage from a plan she hoped would provide protection from huge medical costs throughout the year. 

The Fraser senior citizen now pays her prescription bill - about $700 a month for 16 medications - with her credit card. She waits for the day when her Medicare coverage will kick in again, but that may not come until December - a 1-month reprieve before she starts the 12-month process all over again in January 2007. 

In the meantime, she continues to pay monthly premiums for no coverage. 

So what does Wright think of the Medicare drug program that debuted Jan. 1 and was hailed by President Bush and Washington lawmakers? 

"Not a whole lot," said Wright, 75, who survives on a $1,200 monthly Social Security check. "I wish it was like Canada's system. I've got relatives over there and their drugs are paid for." 

The doughnut hole Wright is experiencing - and perhaps millions of elderly Americans will endure in the coming months - is a quirk in the Medicare program that had garnered limited attention.

The provision requires a halt in coverage after a senior has received $2,100 in benefits. The Medicare coverage stops until the senior pays another $3,600 in out-of-pocket costs. At that point, they are deemed a "catastrophic" case and Medicare pays 95 percent of their drug costs for the rest of the year. 

The gap in coverage was created as lawmakers crafting legislation struggled to hold down the costs of the massive new program. The benefits were limited to $2,100 but Congress also wanted to provide catastrophic coverage for those whose annual drug costs reached several thousand dollars. 

So, the doughnut hole was born. 

One Medicare estimate had indicated that the average senior with high drug costs would fall into the gap in October. But at the Area Agency on Aging, which assisted thousands of area seniors during the chaotic enrollment period, staffers are not surprised that some recipients are already seeing their benefits cease. 

"We expected it," said Carrie Nicholson, the Medicare coordinator for AAA Region 1-B, which covers the six-county southeast Michigan area. "Some will get out of the doughnut hole, some won't."

The problem revolves around a yearly cycle, with benefits starting anew on Jan. 1. Seniors can switch to a different insurance plan in January - six of the 41 offered in southeast Michigan have no doughnut hole. But, in exchange, the plans with no gap charge much higher premiums and require larger co-pays. And seniors are, logically, limited to those plans that cover all of their medications. 

When seniors across the nation were signing up for the program, the confusion that reigned caused many to overlook the implications of the doughnut hole. Now, the Kaiser Family Foundation estimates that 7 million recipients will fall into the gap before the end of the year. 

U.S. Rep. Sander Levin, an outspoken critic of the program, said House Democrats questioned the doughnut hole while Republicans minimized its impact.

 "We worried about this. It was one of the main reasons we opposed the program," said Levin, a Royal Oak Democrat who represents most of Macomb County. "The doughnut hole was one of three or four holes in the plan."

Nicholson of AAA 1-B said seniors who fall into the gap have a few options: ask for free drug samples from their doctor; seek out discounts at local pharmacies or on the Internet; or, though not legal, some may want to get their drugs from Canada. 

In addition, the discount card offered by the Macomb County Department of Senior Citizen Services provides an average savings of 38 percent per prescription. 

Some assistance programs that were previously available, including the state's EPIC program, were eliminated when the Medicare program came to fruition. 

And Medicare recipients are issued this caution: Canadian purchases do not count toward the $3,600 out-of-pocket spending requirement for those in the gap. 

Wright, who lives at the Fraser Woods Senior Community, started in the Medicare program on Jan. 1. In late May, she had no idea that she had reached the doughnut hole until a trip to her pharmacy.

"They said you owe us $600. That was the first time I was notified what had happened," she said. 

Wright's drug plan, provided by Humana, requires a $250 annual deductible, a monthly premium of $13.75, and a payment of 25 percent for each prescription during the initial $2,100 of benefits. 

Because she hit the gap in May, Wright may pay more than $4,500 out of pocket under the Medicare program, about onethird of her annual income. 

Paula Denial, a service coordinator at Fraser Woods, said some low-income seniors may still be forced to choose between food and medicine, even though they?re paying into the Medicare program. 

"I know she's not the only person here who has hit the doughnut hole," said Denial. "We're the people in the trenches. We see how this really works." 

Those seniors who chose to see how the Medicare program really works and have not yet signed up may learn from the pitfalls suffered by Wright and others. Those who ignored the May 15 deadline will pay a penalty, but they may benefit from witnessing the shakeout in the first year. 

In Macomb County, 45 percent of the seniors who had no drug coverage - more than 25,000 - have not enrolled. A new signup period for 2007 is slated for Nov. 15 to Dec. 30. 

Jean Wright of Fraser takes 16 prescription drugs, which cost about $700 a month. Though she is paying into the Medicare drug program, she currently receives no coverage.

Macomb Daily staff photo by David Dalton

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