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The transition to a nursing home or other long-term care facility brings lots of questions and changes in how you get the prescription drugs you need. Fortunately, Medicare makes provisions for your prescription drug coverage when you are in a nursing home. Here’s what you need to know.
How does Medicare cover prescription drugs if I am in a nursing home?
It depends on whether you are in a nursing home that provides mainly custodial care or in a skilled nursing facility on a qualifying stay under Medicare Part A. If you are in a nursing home for skilled nursing care and rehabilitative services following a covered stay in the hospital, your prescription drugs are generally covered under Part A, although your Part A deductible and coinsurance amounts may apply.
On the other hand, if you are in a nursing home or other long-term care facility because you need help with the basic activities of living, such as eating, bathing, or using the bathroom, Original Medicare (Part A and Part B) generally does not cover your prescription drugs. You will usually need to enroll in Medicare Part D prescription drug coverage if you want help paying for your medications.
In general, if your stay in the nursing home is covered by Medicare, your prescription drugs will also be covered. If Medicare is not paying for your stay, you will need Part D coverage for prescription drugs from a private insurance company.
How do I choose Part D coverage for prescription drugs if I am in a nursing home?
Most nursing homes get their prescription drugs from a long-term care pharmacy, so you need to choose a stand-alone Part D Prescription Drug Plan or Medicare Advantage prescription drug plan that contracts with the pharmacy your nursing home uses. If you don’t currently have Medicare Part D coverage for prescription drugs, be sure to check with the plans you are considering to ensure they work with the pharmacy your nursing home uses.
If you already have a stand-alone Medicare Part D Prescription Drug Plan or Medicare Advantage prescription drug plan, contact your plan to make sure the pharmacy your nursing home uses is contracted with your plan.
What if my Part D prescription drug plan doesn’t contract with my nursing home pharmacy?
Under Medicare guidelines, if you are admitted to a nursing home or other long-term care facility, you have the right to make changes to your Medicare plan and Part D coverage for prescription drugs without penalty.
At any time during your stay, you can:
- Join a Medicare Advantage plan with coverage for prescription drugs.
- Join a stand-alone Medicare Part D Prescription Drug Plan.
- Switch from one Medicare Advantage plan to another.
- Switch from one Medicare Part D Prescription Drug Plan to another.
- Return to Original Medicare and drop your Medicare Advantage plan.
These special enrollment guidelines apply for as long as you are in a nursing home or other long-term care facility and extend two full months once you are discharged.
Does Medicare cover all my prescription drugs while I’m in a nursing home?
If your stay is covered by Part A, Medicare generally pays for all your prescription drugs while you are in a nursing home. If you are in a nursing home for custodial care, your coverage is determined by your particular plan’s formulary, which is a list of covered medications and the amount you pay for each. A formulary can change at any time and your plan will notify you if necessary.
It’s important to note that you may have to meet a deductible or pay a copayment for your medication under your Part D coverage for prescription drugs. If you are joining a new Part D prescription drug plan or switching to a different one, be sure to find out the details about your financial responsibility while you are in a nursing home.
This article is only for general information and is not medical advice. Talk to your doctor and the pharmaceutical staff at the nursing home for guidance.