Medicare Part D Coverage During a Skilled Nursing Home Stay
When you’re in a nursing home, you might be given prescription drugs. Even if you’re normally covered under Medicare Part D, are your prescriptions still covered in a nursing home?
Medicare Part D is optional coverage designed to help you pay for prescription drugs. You can get Medicare Part D coverage in either of two ways:
- Through a stand-alone Medicare Part D prescription drug plan
- Through a Medicare Advantage prescription drug plan
Both kinds of plans are available through private, Medicare-approved insurance companies. .
If I’m in a nursing home, will Medicare Part D help pay for my medications?
If you are in a nursing home or other skilled nursing facility, your Medicare prescription drug plan might cover your medications.
Usually Medicare Part A (rather than Medicare Part D) may covers your prescription drugs if you are admitted to a skilled nursing facility (nursing home) following discharge from a Medicare-approved hospital stay. Generally, Medicare Part A coverage must meet specific requirements:
- You must be enrolled in Medicare Part A (or a Medicare Advantage plan).
- The nursing home must be a Medicare-approved facility;
- You must be receiving skilled nursing care.
However, Medicare Part A nursing home coverage is generally temporary. Typically, your Medicare prescription drug plan may pay for your covered prescription drugs if you live in a Medicare-approved nursing home permanently.
If I live in a nursing home, how does my Medicare Part D coverage work?
Every Medicare prescription drug plan has a list of covered medications called a formulary. The formulary typically lists a copayment or coinsurance amount to pay for each covered drug. Generally, this is your cost-share—that is the amount that you pay for the prescription drug–and the plan pays the balance of the prescription cost. However, you might need to pay an annual deductible amount before the plan covers your prescriptions.
The nursing home may have a contract agreement with a pharmacy. If the pharmacy isn’t in your Medicare prescription drug plan’s network, you might need to switch plans.
If you’re in a nursing home and your Medicare prescription drug plan doesn’t cover one of your existing medications, the plan must fill a 30-day supply of your medication unless a shorter duration is prescribed. If your request is denied, you have the right to appeal the decision. Even if the plan does not cover your prescription drugs, the nursing home’s pharmacy should provide your prescription drugs. You may be charged the full amount of the medication, however.
If I live in a nursing home, how does my Medicare Part D coverage work if I have Medicare and Medicaid?
Generally Medicare prescription drug plans coordinate benefits with other insurance. If you have Medicaid and Medicare coverage, usually Medicare will automatically enroll you in a Medicare prescription drug plan under Medicare Part D. You can change to another plan if you want.
Typically, you will pay a small amount for covered prescription drugs if you have Medicaid and Medicare Part D. If you have full coverage from Medicaid and live in a nursing home, you may pay nothing for covered prescription drugs. (If you live in an assisted living facility or residential home, you may pay a copayment for each medication.)
Do you want to take a look at Medicare prescription drug plans in your area? You can compare stand-alone Medicare Part D prescription drug plans and Medicare Advantage prescription drug plans. You can even enter your medications to see which plans cover them. Simply enter your zip code and click the button on this page.