​FAQ: Nursing Facility — Medicare Part D

Please note, that while Medicare Part D is a federal program, not a state program, nursing facilities have been asking questions about the Medicare D Program as it relates to the Medical Assistance (MA) program. The following questions and answers were prepared to provide answers to the questions received.

Drug Deduction

No. Medicare is responsible for all medically necessary drugs. If the appeals process determines a drug is not medically necessary through the Medicare Part D appeals process, MA will not cover the drug and it cannot be deducted as a drug deduction (value code 25) OME.

Once a drug has been determined not medically necessary through the Medicare appeals process, the resident would be responsible for payment. A provider may bill an MA recipient for a incompensable service or item if the recipient is told before the service is rendered that the program does not cover it. 

Vitamin B-12 may be used as a drug deduction. Residents will still be able to get certain drugs with their ACCESS card. Your pharmacy may bill MA directly for these drugs. The types of drugs that the ACCESS card will cover are:

  •  Barbiturates like Phenobarbital
  • Benzodiazepines like Ativan
  • Some over-the-counter drugs like insulin supplies
  • Prescription vitamins and minerals like Folic Acid products, Vitamin D products, Vitamin K products

No amount may be deducted. However, there are plans available without premiums.

Private Insurance

Should the resident choose private insurance, they would be responsible for co-payments and deductibles. The premium cannot be taken as an insurance deduction.