Do Medicare Advantage Plans Cover Skilled Nursing Facilities?
Navigating the potential Medicare Advantage plans in 2025 could be challenging, especially when it comes to understanding the possible ins and outs of Medicare Advantage plans. With countless options and varying levels of coverage, it’s essential to be well-informed before making a decision.
A common question that might be asked is if Medicare Advantage plans cover skilled nursing facilities. This article is designed to help you understand the Medicare Advantage coverage for skilled nursing facilities and help you make the best decision for your healthcare needs.
This article will explore the basics of Medicare Advantage plans, compare them to traditional Medicare, examine potential benefits, and navigate the possible costs and finding the right plan for you.
Key Takeaways
- Some Medicare Advantage plans may offer coverage for skilled nursing facility care, which could come with varying levels of benefits and restrictions.
- Traditional Medicare could provide basic coverage for semi-private room stays, meals, skilled nursing care delivered by qualified staff, and rehabilitation services.
- Alternative options may be available to cover certain long-term care expenses that may not be included in Medicare Advantage plans such as self-funding or annuities.
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Medicare Advantage and Skilled Nursing Facilities: What’s Covered?
Recognizing the distinction between long-term care facilities and skilled nursing facilities will likely be key for healthcare coverage. While both provide 24-hour care and personal care services, these facilities are funded and charged differently.
So, could Medicare Advantage plans cover skilled nursing facilities? It’s not a clear-cut answer.
Bear in mind that coverage for skilled nursing facilities may differ based on the specific Medicare Advantage plan, and your health condition, among other factors.
The Basics of Medicare Advantage Plans
Medicare Advantage plans are private health plans that could potentially serve as an alternative to the traditional government-sponsored program. These plans will likely integrate Medicare Part A and Part B into a single plan, and might even offer additional benefits that may not be available under Original Medicare.
Some of the types of Medicare Advantage plans could include:
- Health Maintenance Organization (HMO) plans
- Preferred Provider Organization (PPO) plans
- Private Fee-for-Service (PFFS) plans
- Medicare Medical Savings Account (MSA) plans
- Special Needs Plans (SNP)
While Medicare Advantage plans will likely offer the same services as Original Medicare, there are some differences. For example, some plans may have restrictions on certain out-of-pocket spending and may require enrollees to use a network of providers.
Coverage for Skilled Nursing Facility Care
Certain Medicare Advantage plans may offer coverage for stays in skilled nursing facilities. However, coverage for skilled nursing facility care will likely depend on several factors, such as:
- Collaborating with your doctor, healthcare providers, social workers, and family to identify the facility that could best meet your needs.
- Skilled nursing facility and nursing home stays may be covered for up to 100 days.
- Beyond 20 days, some plans might require coinsurance.
- Beyond that, residents may be required to cover expenses independently.
It’s important to note that Medicare Advantage plans must provide, at least, the same benefits as traditional Medicare, which could include up to 100 days of skilled nursing home care annually. However, some Medicare Advantage plans may limit coverage for skilled nursing or rehab services, potentially leading to a shorter length of stay at the facility and reduced coverage for rehabilitation therapy.
Factors Affecting Coverage
Certain requirements need to be fulfilled for eligibility for skilled nursing facility coverage under Medicare Advantage. The patient must have been hospitalized for a minimum of three days and must go to a Medicare-certified skilled nursing facility within thirty days of their hospital discharge. Some Medicare Advantage plans may impose certain limitations on coverage for skilled nursing or rehab services, potentially resulting in a shorter length of stay at the facility and reduced coverage for rehabilitation therapy.
The required level of care could significantly influence the coverage that could be provided by Medicare Advantage for certain skilled nursing facilities. Adequate documentation must be submitted to verify that skilled care is necessary, and prior authorization may be required for certain treatments.
Comparing Traditional Medicare and Medicare Advantage
Understanding the differences between traditional Medicare and Medicare Advantage could be key to making a sound decision about your healthcare coverage.
Traditional Medicare, also known as Original Medicare, consists of separate Part A and Part B coverage, while Medicare Advantage combines Part A and Part B into one plan, potentially providing additional benefits beyond what could be covered by traditional Medicare.
Traditional Medicare Coverage
Traditional Medicare may provide coverage for a semi-private room and meals, skilled nursing care delivered by nursing staff, and rehabilitation services, which could include physical therapy, for skilled nursing facilities. To be eligible for skilled nursing facility coverage under traditional Medicare, the patient must visit a Medicare-certified facility within thirty days of their hospital discharge.
Traditional Medicare may also offer coverage for stays in a skilled nursing facility for the initial 20 days and may even cover the cost of medications in skilled nursing facilities.
While traditional Medicare could potentially provide basic coverage for skilled nursing facilities, it may have some limitations compared to Medicare Advantage plans.
Potential Advantages and Disadvantages
Some of the potential advantages of selecting traditional Medicare might include the capacity to visit any provider that accepts Medicare and potentially having more freedom in selecting healthcare services.
On the other hand, Medicare Advantage could offer the convenience of having all your healthcare needs managed by one plan, which may lead to lower out-of-pocket costs, and extra benefits not provided by traditional Medicare, such as dental, vision, and hearing coverage.
However, the advantages and disadvantages of each option may vary depending on individual situations and preferences. It is essential to weigh the possible benefits and drawbacks of each option before deciding.
Possible Benefits of Medicare Advantage
Certain Medicare Advantage plans may be known for offering additional benefits beyond what is included in Original Medicare. Some of these benefits could make a significant difference in the quality of care and overall healthcare experience for enrollees.
Some of the extra perks that could come with certain Medicare Advantage plans might include:
- Prescription drug coverage
- Dental coverage
- Vision coverage
- Hearing coverage
Some of these additional benefits may help enhance the healthcare coverage and support for Medicare Advantage plan members.
From the possibility of having prescription drug coverage to dental services, some of the Medicare Advantage plans could offer a variety of benefits that may cater to the diverse needs of their enrollees.
Prescription Drug Coverage
Certain Medicare Advantage plans may provide prescription drug coverage through Medicare Part D. The difference between Medicare Advantage prescription drug coverage and standalone Medicare Part D plans will likely be the fact that some of the Medicare Advantage plan may provide additional benefits beyond prescription drugs, such as dental, vision, and hearing coverage.
It is important to note that potential exceptions or limitations may exist in the prescription drug coverage that could be provided by Medicare Advantage plans, and plan sponsors may consider granting exception requests for medically necessary drugs.
Some of the expenses that could be associated with prescription drug coverage in certain Medicare Advantage plans may include:
- A monthly premium
- A yearly deductible
- Copayments or coinsurance
- Costs in the coverage gap
Understanding the potential costs and coverage of prescription drug benefits is essential when selecting a Medicare Advantage plan.
Navigating Potential Costs and Finding the Right Plan
Selecting the appropriate Medicare Advantage plan could be a pivotal decision that could affect your healthcare experience and overall well-being. Understanding the potential costs that may be linked with various plans and balancing them against the coverage and benefits will likely be important.
Out-of-Pocket Costs
The out-of-pocket costs that could be associated with certain Medicare Advantage plans may vary. Here are some typical cost-sharing elements:
- Premiums
- Deductibles
- Co-payments
- Coinsurance
Deductibles in some Medicare Advantage plans may operate by requiring you to pay a predetermined amount out-of-pocket before your plan begins to cover some of the expenses of your medical services or prescription drugs.
In certain Medicare Advantage plans, copayments are fixed amounts paid for specific services, while coinsurance involves sharing costs according to a percentage of the total cost.
Tips for Choosing a Medicare Advantage Plan
To determine if a Medicare Advantage plan fulfills your healthcare needs, a comprehensive analysis of the potential benefits, coverage, and costs of the plan options available to you may be necessary. Comparing the coverage and costs of different plans could help ensure you obtain the most advantageous outcome from your Medicare plan.
Some of the highest-rated Medicare Advantage plans will likely include:
- Humana
- Blue Cross Blue Shield
- Aetna
- UnitedHealthcare
- Cigna
- Anthem
These plans will likely be highly rated due to their low-cost availability, comprehensive coverage, and expansive provider networks.
The Medicare Advantage plan network may also influence the selection of a plan by potentially offering a broad range of physicians, hospitals, and other care providers from which enrollees could obtain care.
If you prefer to see particular doctors or hospitals that are not in the plan’s network, you may have to choose a different plan or potentially pay higher co-pay and co-insurance amounts when you see out-of-network providers. Remember to weigh the potential benefits and drawbacks of each option before deciding.
Long-Term Care and Medicare Advantage
Long-term care may be a major concern for many individuals, and comprehending the scope of coverage that could be provided by Medicare Advantage plans is key.
Although some Medicare Advantage plans may provide coverage for certain long-term care services, remember that coverage for long-term care may differ depending on the specific Medicare Advantage plan, your health condition, and other factors.
Alternative Options for Long-Term Care
In addition to Medicare Advantage, there may be several alternative options for long-term care coverage, such as self-funding, group long-term care insurance, long-term care annuities, deferred lifetime annuities, health savings accounts, critical illness insurance, and utilizing home equity
Annuities could be employed to leverage some of the long-term care costs by:
- Potentially adding a long-term care rider that may provide benefits for long-term care expenses
- Distributing taxable gains into certain tax-free benefits for long-term care
- Utilizing a 1035 exchange to help allocate a portion of annuity funds to cover long-term care expenses while preserving retirement income.
Summary
Understanding the intricacies of the potential Medicare Advantage plans and their coverage for skilled nursing facilities will likely be essential for making informed healthcare choices. This article has explored the basics of Medicare Advantage plans, compared them to traditional Medicare, examined their potential benefits, and provided guidance on navigating costs and finding the right plan for you.
Remember to weigh the possible pros and cons of each option and consider your unique needs and preferences when selecting a plan, possibly ensuring you receive the best possible care and support throughout your healthcare journey.
Frequently Asked Questions
→ Why do nursing homes like Medicare Advantage plans?
Some SNFs may like certain Medicare Advantage plans due to their lack of authorization requirements, flexible lengths of stay, and higher reimbursement rates.
→ How many days will Medicare pay 100% of the covered costs of care in a skilled nursing care facility?
Medicare could cover up to 100 days of care in a skilled nursing facility, with the first 20 days covered at 100%. Eligibility and potential costs must be met during the benefit period.
→ What will Medicare cover up to a skilled nursing facility?
Medicare may cover up to 100 days of care in a skilled nursing facility (SNF) during each benefit period. If you need more than 100 days of SNF care in a benefit period, you might have to pay out of pocket and the facility may not be required to provide written notice if care is ending due to running out of days.
→ Does Medicare Advantage cover skilled nursing facilities?
Yes, certain Medicare Advantage plans may offer coverage for stays in skilled nursing facilities. Coverage may vary depending on plan type and other factors.
→ What is the difference between traditional Medicare and Medicare Advantage?
ZRN Health & Financial Services, LLC, a Texas limited liability company
Russell Noga is the CEO of ZRN Health & Financial Services, and head content editor of several Medicare insurance online publications. He has over 15 years of experience as a licensed Medicare insurance broker helping Medicare beneficiaries learn about Medicare, Medicare Advantage Plans, Medigap insurance, and Medicare Part D prescription drug plans.