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Title: Medicare Part D: Don’t Let it Sink Your Nursing Home Reimbursement
Author: Joseph J. Tomaino, M.S., RN

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Medicare Part D: Don’t Let it Sink Your Nursing Home Reimbursement

Article Summary: This article summarizes the challenges faced by nursing homes brought about by the new Medicare Part D drug reimbursement program.  Practical and effective strategies to address these challenges are offered.

On January 1, the new Medicare Part D program went into effect. While this program offers relief to the many older Americans who had no coverage for their medications, and who often had to decide between buying food and taking their medicine, it has offered new challenges to long term care providers. Prior to Part D, the medications given during a Part A Medicare stay in a nursing home was largely the responsibility of the nursing home, with a few exceptions. This remains the same with Part D, and the same cost control strategies (e.g. discontinuing use of low molecular weight heparin medications used for prevention of DVT as soon as patient is ambulatory) that have been used with this population of patients are appropriate to continue. The new wrinkle is the coverage for medications of the patients who are dual eligible and not on a Part A stay-- the chronic or long term population of residents. These residents have had to select a provider for their coverage under Part D, even though the medications continue to be filled by the facility pharmacy or vendor pharmacy. Each of these providers has a separate formulary of covered medications. A drug that may be preferred by one provider may not be by another. This has presented a challenge for facilities to educate their medical providers on these variances. Calls to physicians and nurse practitioners from the pharmacy, laminating formulary coverage grids of the various providers, and meetings of staff and pharmacy consultants are strategies that should be utilized for this purpose. Medicare Part D verses Part B Issues: Medicare has been issuing guidance regarding the determination if a medication qualifies for coverage under Medicare Part D or Part B. Some clarifications include:

• While certain medications given through nebulizer or pump are covered under Part B in a home care setting, they are not in the nursing home setting

• Part B covers three categories of drugs: oral anti-cancer, oral anti-emetic drugs given within 24 to 48 hours of chemotherapy and immunosuppressive drugs for transplants paid for by Medicare. The list of these covered drugs changes frequently, and should be consulted periodically.

It is best to check with your local fiscal intermediary for clarification on the above issues, since there may be local interpretation of Medicare guidance. The final challenge is the long term care resident who is not covered by Medicare at all. For these residents, their medications are not covered by Part D. In most cases they were covered by Medicaid previously. In New York, these residents are now covered by a small add on to their daily rate, but many providers are finding that this rate is far from adequate to cover the medications. Facility staff should track these residents and their associated costs, and apply the same cost reducing strategies used for the Medicare Part A patients where the facility is singularly responsible for the cost of the medications. Part D will continue to present a challenge throughout 2006. Be sure that you are tracking your pharmacy costs, implementing your cost reducing strategies, and keeping your staff informed of the latest facts.

Joseph Tomaino is a patient care executive, educator, and consultant.  His business, The Tomaino Group, provides consultative services and products that support the cost effective provision of quality patient care in acute, sub-acute, long term care, and home care settings.

© Copyright, 2006 All rights reserved, Joseph J. Tomaino, The Tomaino Group, 834 Heritage Court, Yorktown Heights, NY 10598  Email:

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