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Medicare Part D Payments During Covered Part A SNF Stay

Announced on  | Last Modified on  | Project Number: A-09-21-03008
Status
Completed
Agency
Centers for Medicare and Medicaid Services

OBJECTIVE

Medicare Part A prospective payments to skilled nursing facilities (SNFs) cover most services, including drugs and biologicals furnished by the SNF for use in the facility for the care and treatment of beneficiaries. Accordingly, Medicare Part D drug plans should not pay for prescription drugs related to posthospital SNF care because these drugs are already included in the consolidated payment for Part A SNF stays. We will determine whether Medicare Part D paid for drugs that should have been paid under Part A SNF stays.

TIMELINE

REPORT PUBLISHED

Medicare Part D Paid Millions for Drugs for Which Payment Was Available Under the Medicare Part A Skilled Nursing Facility Benefit (A-09-21-03008)

25-A-09-003.01 to CMS - Open Unimplemented
Update expected on 10/22/2025
We recommend that the Centers for Medicare & Medicaid Services work with its plan sponsors to adjust or delete PDEs, as necessary, and determine the impact to the Federal Government related to the Medicare Part D total costs of $953,370 for drugs associated with our sample items for which payment was available under the Medicare Part A SNF benefit, which included $541,652 for drugs that were administered during Part D enrollees' Part A SNF stays.

25-A-09-003.02 to CMS - Open Unimplemented
Update expected on 09/27/2025
We recommend that the Centers for Medicare & Medicaid Services work with its plan sponsors to identify similar instances of noncompliance that occurred during our audit period and determine the impact to the Federal Government, which could have amounted up to an estimated $465,077,908 in Part D total cost, including $245,365,324 for drugs that were administered during enrollees' Part A SNF stays.

25-A-09-003.03 to CMS - Open Unimplemented
Update expected on 09/27/2025
We recommend that the Centers for Medicare & Medicaid Services work with its plan sponsors to identify similar instances of noncompliance that occurred before and after our audit period and determine the impact to the Federal Government related to Part D total costs for drugs for which payment was available under the Medicare Part A SNF benefit.

25-A-09-003.04 to CMS - Open Unimplemented
Update expected on 10/22/2025
We recommend that the Centers for Medicare & Medicaid Services provide plan sponsors with timely and accurate information, such as dates of covered Part A SNF stays, to reduce instances of inappropriate Part D payment for drugs for which payment is available under the Part A SNF benefit.

25-A-09-003.05 to CMS - Closed Implemented
Closed on 06/23/2025
We recommend that the Centers for Medicare & Medicaid Services instruct SNFs to cooperate with plan sponsors to identify and prevent improper Part D payments for drugs for which payment was available under the Part A SNF benefit.

View in Recommendation Tracker
Work Plan Type
Office of Audit Services
HHS Agencies
Centers for Medicare and Medicaid Services
Issue Areas
Prescription Drug
Target Groups
Elderly
Financial Groups
Medicare D