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OK, assume you got the bill from the hospital and have been told that the charges were for “self-administered drugs” that Medicare won’t pay the hospital for. You pay the bill and then request partial reimbursement from your Medicare Part D insurer. Your booklet from the insurer will tell you how to file the claim. You will also need to get a detailed bill from the hospital outlining the drugs and their cost for the insurers that will go to the insurer.
Since it is unlikely that your hospital’s pharmacy is in your Part D plan’s network, the copays and deductibles will generally be based upon an out-of-network pharmacy. The drug cost your insurer will use is the cost billed by the hospital and it will only pay for drugs that are on their formulary unless you appeal the claim. As I understand it the insurer will pay as follows:
- If in the deductible – insurer pays nothing
- If in the first period the insurer pays the balance after deducting the co-pay
- If in the donut hole – for brand name drugs the insurer pays the discount (50% for 2012) and you pay the balance – for generics the insurer pays the discount (14% for 2012) and you pay the balance
- If in the catastrophic period the insurer pays 95% you pay the balance
Insurers also seem to be struggling with this based upon my experience. It certainly is an expensive claim to administer since it is likely hand paid versus a computer payment to a local drug store’s account.
In practice many seniors will simply pay the bill from the hospital and never know that there is a high probability of coding mistakes and that they can file for re-imbursement through their Medicare Part D plan. This saves Medicare money and makes money for the local hospital. I hate being a cynic, but I suspect that both Medicare and hospitals know this. For seniors, in many cases, it will mean skipping meals to pay such a bill.
(end of Part 2)