CMS Updates SNF Billing Guidance Related to Part D Drug Coverage

• By: Maureen Carland
• On: 05/29/2025 07:22:32
• In: Quality/Regulatory

The Office of Inspector General (OIG) recently reported that Medicare Part D improperly paid for prescription drugs during Medicare Part A skilled nursing facility (SNF) stays. In response, the Centers for Medicare & Medicaid Services (CMS) has 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. 
Excerpts of the updated guidance include:
•  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. 
 
Staff contact: mcarland@mehca.org