Determining Drug Coverage for Original Medicare

Determining Medicare Drug Coverage

While billing for Skilled Nursing Facilities (SNF) or for hospital billing, billers always make the mistake of considering the wrong Medicare drug coverage. For example, Medicare Part A and Part B generally do not cover outpatient prescription drugs, most of which are covered under Part D. In this article, we shared an excerpt from a CMS document, which will act as a basic tool to assist you in understanding Medicare drug coverage determinations under Part A, Part B and Part D of Medicare, and to clarify coverage for specific Part D products/drugs/categories. 

We also shared billing scenarios, which will help you to determine which part of Medicare covers a drug in a particular situation, assuming all other requirements are met, e.g., a drug must still be medically necessary to be covered. This information is applicable to people in the Original Medicare Plan. People who have a Medicare Advantage HMO or PPO Plan with prescription drug coverage get all their Medicare-covered health care from the plan, including prescription drugs.

Part A Hospital Insurance

People with Medicare who are inpatients of hospitals or skilled nursing facilities (SNF) during covered stays may receive drugs as part of their treatment. Medicare Part A payments made to hospitals and skilled nursing facilities generally cover all drugs provided during a stay. Under the Medicare hospice benefit, people receive drugs that are medically necessary for symptom control or pain relief. Part B can pay hospitals and SNFs for most categories of Part B-covered drugs if a person does not have Part A coverage, if Part A coverage for the stay has run out, or if a stay is not covered.

Part B Medical Insurance 

Medicare Part B covers a limited set of drugs. Medicare Part B covers injectable and infusible drugs that are not usually self-administered and that are furnished and administered as part of physician service. If the injection is usually self-administered (e.g., Imitrex) or is not furnished and administered as part of a physician’s service, it may not be covered by Part B. Medicare Part B also covers a limited number of other types of drugs as shown in the attached chart.1 (Regional differences in Part B drug coverage policies can occur in the absence of a national coverage decision.

Part D Prescription Drug Insurance

Part D-covered drugs are defined as drugs available only by prescription, used and sold in the United States, and used for a medically accepted indication; biological products; insulin; and vaccines. The definition also includes medical supplies associated with the injection of insulin (syringes, needles, alcohol swabs, and gauze). Certain drugs or classes of drugs, or their medical uses, are excluded by law from Part D coverage. While these drugs or uses are excluded from basic Part D coverage, drug plans may choose to include them as part of supplemental benefits, not covered by Medicare.

Medicare Drug Coverage Scenarios

Here below we shared billing scenarios, which would help you to determine which part of Medicare covers a drug in a particular situation (assuming all other requirements are met, e.g., a drug must still be medically necessary to be covered): 

  • If Medicare is covering beneficiary’s stay in a hospital or skilled nursing facility, their drugs will be paid for under Medicare Part A. Part A will stop paying for the drugs when patients leave the hospital or skilled nursing facility or when their benefit runs out, whichever comes first. 
  • If a beneficiary is in a Medicare-approved hospice program, Medicare Part A will pay for drugs for symptom control or pain relief. However, Medicare is not permitted to pay for prescriptions intended to treat the terminal illness. If the beneficiary joins a Medicare prescription drug plan (Part D), drugs unrelated to the terminal illness would be covered by that plan. For instance, if they need medicine to treat an infection unrelated to the terminal illness, it would be covered by the beneficiary’s Medicare prescription drug plan (Part D). 
  • If the drugs are currently covered by Part B, they will continue to be covered by Part B. Beneficiary might join a Medicare drug plan (Part D) to help pay for other drugs that which beneficiary might be taking that are not currently covered by Part B. 
  • If a beneficiary is living in a long-term care facility, any medications they receive under the DME benefit such as nebulizer drugs for lung disease will no longer be covered since that benefit by law is only for services delivered in the home. If they have Medicare prescription drug coverage (Part D), their plan may cover those prescriptions. For this purpose, long-term care facilities include skilled nursing facilities (after Part A coverage is exhausted or for stays not covered by Medicare), nursing homes that give skilled care, and institutions that give skilled care.
  • Please note that if Part A or Part B would cover the prescription drug as it is prescribed and dispensed or administered, that drug will not be paid for by the Medicare drug plan (Part D). 

MedicalBillersandCoders (MBC) is a leading revenue cycle company providing complete medical billing services. We shared applicable billing information on drug coverage for original Medicare for provider education purposes. To know more about ‘Medicare Drug Coverage Under Part A, Part B, and Part D’ you can refer to the CMS document. For any assistance required for Medicare billing, contact us at / 888-357-3226