{"id":15580,"date":"2022-08-03T06:10:36","date_gmt":"2022-08-03T06:10:36","guid":{"rendered":"https:\/\/www.medicalbillersandcoders.com\/blog\/?p=15580"},"modified":"2024-11-29T11:40:57","modified_gmt":"2024-11-29T11:40:57","slug":"determining-drug-coverage-for-original-medicare","status":"publish","type":"post","link":"https:\/\/www.medicalbillersandcoders.com\/blog\/determining-drug-coverage-for-original-medicare\/","title":{"rendered":"Determining Drug Coverage for Original Medicare"},"content":{"rendered":"

Determining Medicare Drug Coverage<\/span><\/h2>\n

While billing for Skilled Nursing Facilities (SNF)<\/a> or for hospital billing<\/a>, 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. <\/span><\/p>\n

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.\u00a0<\/span><\/p>\n

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. <\/span><\/p>\n

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.<\/span><\/p>\n

Part A Hospital Insurance<\/span><\/h3>\n

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. <\/span><\/p>\n

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.<\/span><\/p>\n

Part B Medical Insurance\u00a0<\/span><\/h3>\n

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.<\/span><\/p>\n

Part D Prescription Drug Insurance<\/span><\/h3>\n

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). <\/span><\/p>\n

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.<\/span><\/p>\n

Medicare Drug Coverage Scenarios<\/span><\/h2>\n

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):\u00a0<\/span><\/p>\n