The Centers for Medicare and Medicaid Services (CMS) recently updated the
SNF Billing Reference educational tool to help SNF billers identify where to submit claims when prescription drugs are furnished during a SNF short- or long-stay.
During a SNF Part A stay, drugs prescribed for a Part D-enrolled patient aren’t covered by Part D if Part A or B can pay for them; SNFs should avoid submitting claims to Part D plans in these situations. CMS is updating the guidance in response to a recent Office of Inspector General (OIG)
report that found that Medicare Part D improperly paid for drugs during Part A SNF stays.
Excerpts of the updated guidance include:
It’s important for SNFs to know when to bill a patient’s prescription drugs to Part A, instead of their Part D drug plan, to prevent
improper payments:
- Drugs prescribed for a Part D-enrolled patient aren’t covered by Part D if Part A or B can pay for them.
- Part A covers drugs and biologicals ordinarily provided by SNFs for the patient’s care and treatment.
- Part A covers a limited supply of drugs to use outside a SNF if it’s medically necessary to help a patient leave the facility and is required until they can get a continuing supply.
Medicare drug plan (Part D) coverage may be available to a Part D patient who’s exhausted their Part A inpatient stay benefit but remains in that inpatient setting, if the drug would otherwise be covered under Part D.
Medicare Prescription Drug Benefit Manual, Chapter 6, section 20.2.1 has more information.