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Getting Part D Benefits in a Nursing Home

Q. I have power of attorney for my mother, who has significant memory loss and recently moved into a nursing home. She’s being charged full price for her medications, and although we’re sure she is enrolled in a Medicare Part D drug plan, we can’t find her membership card. What can we do?

A. First, you need to find out if your mother is enrolled in a Part D plan and, if so, which one. You can:

  • Call the pharmacy your mother used before moving into the nursing home and ask whether she is recorded as a Part D plan member in its computer system; or
  • Call the Medicare help line at 1-800-633-4227, explain the situation, and ask them to check whether she is currently enrolled in Part D and, if so, obtain the name and contact information of her plan.

In both instances, you’ll need to give your mother’s Social Security number and provide proof you’re entitled to act on her behalf.

If she’s enrolled in Part D

When you know your mother’s plan, call its customer service number and ask for a new card. She’s entitled to a refund for any bills she’s paid that the plan should have covered—minus any required deductible and copays.

But that isn’t the end of it. You’d be wise to check that the long-term care pharmacy the nursing home uses is within the network of your mother’s drug plan. If it isn’t, the plan won’t cover her drugs. In that case, she should switch to another plan that includes the nursing home’s pharmacy. Medicare beneficiaries who enter a nursing home are entitled to a special enrollment period to change to plans at that time. You have the legal right to act for her, so you can make this switch.

Remember, too, that if your mother is receiving full Medicaid benefits—that is, if her state medical assistance program is paying for the nursing home costs—she will not have to pay premiums or anything else for her prescription drugs after she’s lived in the home for at least one month. But she still must be enrolled in a Part D plan to be eligible for this benefit.

If she doesn’t receive Medicaid, it would be worth checking whether she qualifies for Part D’s Extra Help program that provides low-cost drug coverage for people with limited incomes. Again, she must be enrolled in a Part D plan to receive this assistance.

If she isn’t enrolled in Part D

If you find your mother is not currently enrolled in Part D and has no other drug coverage, she has the right to sign up with a drug plan immediately without waiting for open enrollment at the end of the year. The special enrollment period for people entering a nursing home, mentioned above, can be used to join a plan as well as to switch to another.

She may be charged a late penalty if she’s gone for any length of time without Part D or other “creditable” drug coverage—that is, coverage Medicare considers to be at least as good as Part D. If she qualifies for Extra Help, however, the late penalty is waived.

Patricia Barry is a senior editor at the AARP Bulletin.

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