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Part D Coverage on Nursing Homes

If you are in a nursing home or another qualified institution and receive long-term care, you should know how your prescription drug coverage may be affected. Different rules will apply as to when you can switch plans and how you can 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.
Nursing homes work with specific pharmacies, thus you should choose your plan wisely. If your 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 can 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
  • 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:
  1. 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. You have the right to file an appeal if your plan is denied.
  2. 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.
  3. You can change your drug plan outside the regular enrollment periods.

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