Dear Toni:
Does Medicare Part B cover prescription drugs in an outpatient setting, like emergency room or under observation? You wrote about this last week and we are having this problem. My mother was in the hospital 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 our options are?
Thanks, Sue from Alvin, TX
Hello Sue:
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 clinic.
I started discussing under observation vs inpatient hospital stays in last week’s article, but did not get to explain how prescriptions are covered in the observation setting. Today I will finish this discussion.
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” or hospital outpatient setting, then you may pay for the drug cost out of your pocket.
When I am consulting with someone who is first enrolling in Medicare and they try to justify why they do not need to enroll in a Part D drug plan when they do not take any prescriptions; I simply advise them how important it is to enroll in the least expensive Part D plan. No one knows what the future holds and now with healthcare reform Medicare is doing everything they can to control how they are spending our Medicare dollars.
New Medicare rules are popping up each month to make sure Medicare dollars are being spent wisely.
To keep from paying for prescriptions out of pocket when in the hospital I would advise you to get your mother enrolled in a Part D plan when Medicare’s open enrollment takes place in October 2014.
Here is what one should do when you receive a hospital bill for prescriptions not covered by Part B in a hospital 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.
Research about Part B outpatient hospital setting and Part D was found on the Medicare website at http://www.medicare.gov/Pubs/pdf/11333.pdf
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