UNITED STATES—Dear Toni: I have been told that Medicare does not cover drugs when you are in an emergency room? My husband, Joe went in the hospital from the ER for two days and because it was considered “under observation,” we are now fighting the hospital because they say his drugs were not covered during his stay.
He does not have a Part D plan because he did not take any prescriptions when he turned 65 What should we do? Thanks, Cynthia from Tomball area
Cynthia: Since your husband did not enrolled in a Medicare Prescription Drug Part D plan and his hospital stay falls in “under observation” he might have to pay for the drugs administered because his stay is under Part B which does not cover prescriptions given orally.
Part B (Medical Insurance) covers IV (intravenous infusion) drugs and since your husband was considered outpatient care he was not an inpatient care, which would have qualified for a Medicare Part A – inpatient hospital stay with drugs covered.
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 as you and your husband are experiencing.
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.
The new American Baby Boomer Society website has course #6 which explains Medicare Part D and the famous donut hole. Visit www.abbs4u.com website to join.
To keep Joe from paying for prescriptions out of pocket whether in or out of the hospital, I would advise you to see if he qualifies for Part D “Extra Help” from Social Security or Medicaid. If he qualifies then he can enroll in a Part D plan now or he will have to wait until Medicare’s open enrollment which takes place in October 2018 and enroll in a Medicare Part D plan because he has missed his “initial enrollment period.”
Below is what to do when one receives 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 Part D 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.
· Keep copies of receipts and paper work you send to your Part D plan.
Toni King, author of the new Medicare Survival Guide® offers a Toni Says® Medicare column readers discount available at www.tonisays.com. Email Medicare/long term care questions to firstname.lastname@example.org or call 832/519-TONI (8664).