If you live in a nursing home or another qualified institution (not 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-covered nursing home stay, prescription drugs are covered by Part A, not Part D. The information below is only applicable to Part D coverage of drugs in a 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 or not preferred), you may end up paying higher costs for prescriptions.
If you are in a nursing home, you are able to switch your drug coverage outside regular enrollment periods. 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 to change Part D plans. Your new coverage will begin the first of the month following your enrollment into a new plan.
If your plan does not cover or denies coverage for a drug you need, you have the same right to appeal 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 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).