Dear Toni:

I have been told that Medicare does not cover drugs when you are in an emergency room?  My mother went in the hospital from the ER for 2 days and because it was considered “under observation, we are now fighting the hospital because they say her drugs were not covered during her stay.  She does not have a Part D plan and we do not know what to do?  Please explain what her options are?

Thanks, Sydney from Lafayette,LA


Hello Sydney:

If you are not enrolled in a Medicare Prescription Drug Part D plan and your hospital stay falls in “under observation” you may pay for the drugs administered because your stay is under Part B which does not cover prescriptions given orally.  Part B (Medical Insurance) covers IV (intravenous infusion) drugs and since your mother was considered outpatient care she was not an inpatient care, which would have qualified her for a Medicare Part A- inpatient hospital stay.

Medicare Part B generally covers care that you receive in a hospital outpatient setting like an emergency room, observation unit, and outpatient surgery center or pain.

This is why enrolling in a Part D Medicare drug plan is so important because when you are admitted in a hospital on an outpatient basis you may need your self-administered drugs.  Self-administered drugs are what you would normally take on your own or over the counter type drugs. Part B does not pay for these types of drugs, but a Medicare Part D Prescription Drug plan can.

If you do not have a Part D drug plan while in a Part B “under observation”, hospital outpatient setting or emergency room, then you may pay for the drug cost out of your pocket.

During a Toni Says Medicare consultation, everyone is advised on the importance of enrolling in a Medicare Part D plan when first enrolling in Medicare.

Sydney, to keep your mother from paying for prescriptions out of pocket whether in or out of the hospital, I would advise you to see if your mother qualifies for Part D “Extra Help” from Social Security or Medicaid. She can enroll in a Part D plan now or she will have to wait until Medicare’s next open enrollment which takes place in October 2018 and enroll then because she has missed her initial enrollment period.

Below is what to do when you receive a hospital bill for prescriptions not covered by Part B in a hospital ER or outpatient setting:

  • Most hospital pharmacies do not participate in Medicare Part D; you may need to pay up front and submit the claim to your Medicare drug plan for a refund.
  • Follow instructions on how to submit an out-of-network claim.
  • You may need to forward certain information like emergency room bills that show what self-administered drugs you were given.
  • You might need to explain the reason for the hospital visit
  • Keep copies of receipts and paper work you send to your Part D plan.
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