If you live in a nursing home A nursing home, also called a long-term care facility, is a residential facility for people with chronic illness or disability. Nursing home services include room and board, nursing care, personal care, and therapy services. A skilled nursing facility (SNF) is a nursing home that provides skilled care, but not all nursing homes are SNFs. Medicare does not cover the cost of nursing homes that are not SNFs. or another qualified institution (not an assisted living facility Assisted living facilities are long-term care facilities designed to assist people with activities of daily living who can otherwise take care of themselves. They are different from nursing homes, which also provide skilled care. Medicare does not cover room and board in an assisted living facility. or a group home) and receive long-term care, you should be aware of how your prescription drug coverage may be affected. Specifically, different rules apply as to when you can switch plans and how you access drugs.
Note: During a Part A Part A, also known as hospital insurance, is the part of Medicare that covers most medically necessary hospital inpatient care, skilled nursing facility (SNF) care, home health care, and hospice care. -covered nursing home stay, prescription drugs are covered by Part A, not by Part D. The information below is only applicable to Part D coverage of drugs in a nursing home setting.
Part D drug coverage in nursing home setting
Generally, nursing homes work with specific pharmacies, and you should choose a plan that works with your nursing home’s pharmacy. If you plan does not work with your nursing home’s pharmacy (because it is out of network A network is a group of doctors, hospitals, and pharmacies that contract with a Medicare Advantage Plan to provide health care services. Generally, plan members will have the lowest costs when using providers and facilities in the plan’s network. Networks may be made up of both preferred and non-preferred providers. or not preferred), you may end up paying higher costs for prescriptions.
Changing Part D coverage
If you are in a nursing home, you are able to switch your drug coverage outside regular enrollment periods Enrollment periods are certain periods of time when you can join the Original Medicare program, or enroll in a Medicare Advantage Plan, Part D plan, or supplemental insurance plan (Medigap). See also: Fall Open Enrollment, Medicare Advantage Open Enrollment Period, General Enrollment Period, Initial Coverage Election Period, Initial Enrollment Period, Medigap Open Enrollment Period, and Special Enrollment Period. . Specifically, you can make plan changes:
- When you enter a nursing home
- Once a month while you live in a nursing home
- And, once during the two months after you leave a nursing home
Call 1-800-MEDICARE (1-800-633-4227) to change Part D plans. Your new coverage will begin the first of the month following your enrollment Enrollment is joining Original Medicare or becoming a member of a Medicare Advantage Plan or Part D plan. into a new plan.
Appeal rights in nursing homes
If your plan does not cover or denies coverage for a drug you need, you have the same right to appeal An appeal is a formal request for review if you disagree with an official health care coverage or payment decision made by a Medicare Advantage Plan, a Medicare private drug plan (Part D), or Original Medicare. Federal regulations and law specify appeals deadlines, processes for handling appeals, what information must be included in a decision, and the levels of review in the appeals process. in a nursing home as you would if you lived elsewhere. While living in a nursing home, you also have these additional rights:
- If you live in a nursing home or are entering a nursing home from another setting, your plan must fill a 31-day emergency supply of your drugs outside your transition period while your exception request An exception request is a formal written request to your Part D plan asking that it pay for a drug you need. For example, you can file an exception request to pay for a drug that is not on the plan’s list of covered drugs (formulary), or you can ask the plan to lower the cost of an expensive drug on the formulary (see Tiering Exception). is being processed. (If your request is denied, you have the right to appeal).
- Even if you cannot get your drugs covered, your nursing home should provide you with the drugs you need, though it may charge you for this service.
- You can change your drug plan outside regular enrollment periods (see above).