What does Medicare Part B not cover during an ER visit?
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 two days, and because it was considered “under observation,” we are now fighting the hospital, which says her drugs were not covered during her stay.
She has a Part D plan, but the hospital pharmacy claim is filed out of network. She now has to pay a higher amount.
Please explain what her options are. — Clyde, Lake Charles, La.
Dear Clyde: Medicare Part B covers medical care that you receive in a hospital outpatient setting such as an emergency room, observation unit, outpatient surgery center or pain clinic. Part B covers IV drugs but not prescriptions given orally.
Had your mother’s hospital stay been classified as “inpatient care,” her prescriptions would have been paid for by her Medicare Part A. Because her ER hospital stay was classified as “under observation,” she will have to pay for the drugs administered unless she is enrolled in a Medicare Part D prescription plan.
This is why enrolling in a Part D plan is so important. When you are having a medical issue in the emergency room you may need your self-administered drugs (medications you normally take on your own or other over-the-counter drugs) to be covered through your Part D plan. Part B does not pay for these types of drugs, but a Medicare Part D plan can.
If you do not have Part D while “under observation” in hospital outpatient setting or emergency room with Part B, then you will have to pay the drug cost out of pocket.
The Toni Says Medicare team urges people to enroll in a Part D plan even if they do not currently take prescriptions.
For readers on Medicare who have missed their Part D enrollment deadline, I would recommend signing up for a plan during Medicare’s open enrollment period (Oct. 15-Dec.7) to keep from receiving further Part D penalties.
But here is what to do when you receive a hospital bill for prescriptions not covered by Medicare Part B in a hospital outpatient setting:
■ Most hospital pharmacies do not participate in Medicare Part D; you may need to pay upfront and submit the claim to your Part D drug plan for a refund.
■ Follow instructions on how to submit an out-of-network claim.
■ You may need to send certain information such as emergency room bills that show which self-administered drugs you were given.
■ You might need to explain the reason for the hospital visit.
■ Keep copies of receipts and paperwork you send to your Part D plan.
Toni King is an author and columnist on Medicare and health insurance issues. If you have a Medicare question, email info@tonisays.com or call 832-519-8664.
