Out-of-network Part D coverage explained

If a person is inpatient in the hospital, all services provided — including medications — are covered under Medicare Part A. However, a person staying overnight in the hospital could be outpatient — either deemed on observational status or in the emergency room. Medicare Part B covers outpatient hospital and emergency room visits. However, Medicare Part B does not pay for self-administered medications. Self-administered medications are drugs which a person can take independently, without the help of a doctor or nurse. Usually these are pills taken orally and injections that go just under the skin. Insulin is one such example since it is injected just under the skin, not into a muscle or vein. Since Medicare Part B does not cover self-administered drugs, there will be an appropriate denial on the Medicare Summary Notice for these charges.

But a person is not stuck paying the entire claim if he or she is enrolled in a Medicare Part D plan. Every Part D plan has a policy on out-of-network coverage, usually at a much lower coverage level than in-network coverage. A person can self-submit a claim for reimbursement of the medications costs by filling out an Out of Network Reimbursement Request form from the Part D plan. The reimbursement request should be accompanied by a copy of the hospital medication invoice and evidence of payment. The Part D plan will send a partial reimbursement to the consumer directly. Note that these requests usually need to be submitted within 30- 60 days following the hospital stay.

Unfortunately, people who have SeniorCare alone do not have this option for submission of out-ofnetwork claims. Consumers cannot self-submit claims to SeniorCare, and so there is no mechanism for payment to a pharmacy that does not accept SeniorCare. Therefore, people with only SeniorCare for drug coverage will have to pay those self-administered medications costs out of pocket.

If you have any additional questions, you may call Pat Hafermann, Elderly Benefits Specialist with the Aging and Disability Resource Center at (920) 467-4076. Sources: Published with permission from the Legal Services Team at the Greater Wisconsin Agency on Aging Resources’ Elder Law & Advocacy Center


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