If you live in a nursing home or another qualified institution (not an assisted living facility or a group home) for long term care, you should know these important facts about the Medicare drug benefit (Part D). Note that if your stay in a nursing home is being covered under the Medicare Skilled Nursing Facility (SNF) benefit, your prescription drugs will be covered by Medicare Part A, not by your Medicare private drug plan (Part D).

Choosing a plan:

  • Generally, nursing homes work with specific pharmacies. You will want to choose a plan that will work at the pharmacy your nursing home uses.

Paying for Drug Coverage:

 

Switching Plans:If your Medicare drug plan does not meet your needs and you live in a nursing home, you will be able to change drug plan. In addition to the regular enrollment periods available to everyone with Medicare drug coverage, you will be able to switch plans:
  • 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.

To change plans, it is best to enroll through 1-800-MEDICARE, rather than calling the new plan, to avoid administrative errors. Your new coverage will begin the following month after you have submitted a completed enrollment form to the plan.

Getting drugs that are not covered by your plan:

If your Medicare drug plan does not cover a drug that you need, you have all the same rights as everyone else with Medicare drug coverage plus:

  • During the first 90 days that you join a new Medicare private drug plan, your plan must cover 31-day supplies of your medication—with multiple refills as necessary. During this transition period your doctor should help you change your drug to another one covered by your plan or help you get an exception (see below).
  • 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 of your transition period while your exception is being processed.
  • If you cannot get your drugs covered, your nursing home should provide you with the drugs you need (your nursing home may charge for this service).
  • You can change your Medicare drug plan (see above).