Do Medicare Advantage Plans Cover Skilled Nursing Facilities?

Medicare Advantage plans serve as a private alternative to Original Medicare, offering a bundled approach to health and drug coverage. These plans, often called Part C, are provided by private companies approved by Medicare. They incorporate Medicare Part A (Hospital Insurance) and Part B (Medical Insurance), and frequently include Part D (prescription drug coverage) along with additional benefits. While the specific terms and benefits can vary significantly between plans, Medicare Advantage plans do cover skilled nursing facility (SNF) care. This coverage is subject to certain conditions and cost-sharing requirements, which differ from those under Original Medicare.

Understanding Skilled Nursing Facility Coverage

Skilled nursing care is medical care provided by licensed healthcare professionals, such as nurses or physical therapists, under a doctor’s orders. This care is distinct from custodial care, which involves assistance with daily activities like bathing or dressing by non-medical personnel. Medicare Advantage plans, like Original Medicare, only cover medically necessary skilled nursing care, not long-term custodial care. Skilled care aims to treat injury or illness, aid recovery, or maintain a condition to prevent worsening.

To qualify for SNF coverage, a person needs a qualifying inpatient hospital stay of at least three consecutive days. This means the individual must have been formally admitted to the hospital as an inpatient, not just under observation status in the emergency room. The SNF admission must occur within 30 days of leaving the hospital. The care received in the SNF must be for the same condition treated during the hospital stay or a new condition that arose while receiving SNF care for the original condition.

The care must require daily skilled nursing or therapy services that can only be provided in a Medicare-certified SNF. Examples of skilled care include physical therapy, wound care, or intravenous injections. While Original Medicare covers up to 100 days of SNF care per benefit period, Medicare Advantage plans also cover up to 100 days, though specific terms can vary by plan. A benefit period begins when a person is admitted as an inpatient to a hospital or SNF and ends when they have not received inpatient care for 60 consecutive days.

Financial Aspects of Skilled Nursing Facility Stays

The financial obligations for skilled nursing facility stays under a Medicare Advantage plan involve deductibles, copayments, and coinsurance. Unlike Original Medicare, with a specific cost structure (e.g., no cost for the first 20 days, daily copayment for days 21-100), Medicare Advantage plans set their own SNF cost-sharing. These amounts vary significantly, so review your plan’s Evidence of Coverage (EOC) for precise details.

A deductible is the out-of-pocket amount paid before coverage begins. Copayments are fixed amounts for a service, while coinsurance is a percentage of the total cost. Medicare Advantage plans cannot charge higher copayments than Original Medicare for certain services like SNF care, but their overall cost-sharing models differ.

Medicare Advantage plans include an annual out-of-pocket maximum, a protective feature absent in Original Medicare. This limit caps the amount an enrollee pays for covered Part A and Part B services annually, including SNF costs. For 2025, the in-network out-of-pocket limit cannot exceed $9,350, with higher limits for plans including out-of-network coverage. Once this maximum is reached, the plan covers 100% of covered services for the remainder of the plan year.

Accessing and Managing Your Skilled Nursing Facility Benefit

Utilizing a Medicare Advantage SNF benefit requires understanding specific procedural requirements set by the private plan. A key aspect is network restrictions; many Medicare Advantage plans require patients to use in-network SNFs for coverage. Using an out-of-network SNF without proper authorization may result in no coverage or significantly higher out-of-pocket expenses.

Most Medicare Advantage plans require prior authorization for SNF admissions and continued stays. This process involves the plan reviewing medical necessity before approving coverage. While Original Medicare rarely requires prior authorization for SNF admissions, Medicare Advantage plans frequently do, which can sometimes lead to delays in admission. The patient’s doctor typically submits the prior authorization request, providing medical documentation to support the need for skilled care.

Admission from a hospital to an in-network SNF typically involves coordination between the hospital’s discharge planner and the Medicare Advantage plan. Discharge planners work with patients and families to determine suitable post-hospital care, considering factors like medical needs and available services. They facilitate the transition, ensuring the SNF is Medicare-certified and in-network.

Once admitted, the Medicare Advantage plan actively monitors the SNF stay for ongoing medical necessity. This involves periodic reviews and assessments to ensure continued need for skilled care. If the plan determines that skilled care is no longer medically necessary, coverage may end, even if the 100-day limit has not been reached. Patients have the right to appeal coverage decisions if they believe their care is still medically necessary.