Do Medicare Advantage Plans Cover Skilled Nursing Facilities?

Navigating the complex world of Medicare Advantage plans in 2025 can be challenging, especially when it comes to understanding the 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 often asked is if Medicare Advantage plans cover skilled nursing facilities. This article is designed to help you unravel the mysteries of Medicare Advantage coverage for skilled nursing facilities and empower you to make the best decision for your healthcare needs.

We’ll explore the basics of Medicare Advantage plans, compare them to traditional Medicare, examine additional benefits, and provide guidance on navigating costs and finding the right plan for you. Let’s dive into the intriguing world of Medicare Advantage and skilled nursing facilities, with a focus on understanding if Medicare Advantage plans cover skilled nursing facilities.

 

Key Takeaways

 

  • Traditional Medicare provides basic coverage for semi-private room stays, meals, skilled nursing care delivered by qualified staff, and rehabilitation services.

 

  • Alternative options are available to cover long-term care expenses not included in Medicare Advantage plans such as self-funding or annuities.

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Medicare Advantage and Skilled Nursing Facilities: What’s Covered?

 

Do Medicare Advantage Plans Cover Skilled Nursing Facilities?, Medicare Advantage and Skilled Nursing Facilities: What's Covered?

 

Recognizing the distinction between long-term care facilities and skilled nursing facilities is key for healthcare coverage. While both provide 24-hour care and personal care services, they are funded and charged differently.

So, do Medicare Advantage plans cover skilled nursing facilities? It’s not a clear-cut answer.

Over the years, coverage for skilled nursing facilities has been decreasing. Considering this, we shall examine the basic principles of Medicare Advantage plans and their coverage scope for skilled nursing facilities.

Bear in mind that coverage for skilled nursing facilities can differ based on the specific Medicare Advantage plan, and your health condition, among other factors.

Keep reading to learn more about the basics of Medicare Advantage plans, coverage for skilled nursing facilities, and factors that affect coverage.

 

The Basics of Medicare Advantage Plans

Medicare Advantage plans are private health plans that serve as an alternative to the traditional government-sponsored program. These plans integrate Medicare Part A and Part B into a single plan, offering additional benefits not available under Original Medicare.

Some of the types of Medicare Advantage plans available 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 offer the same services as Original Medicare, there exist some differences. For example, these plans generally have restrictions on out-of-pocket spending and require enrollees to use a network of providers.

Having grasped the basic concept of Medicare Advantage plans, we should examine the coverage they extend for skilled nursing facility care, including whether Medicare covers nursing homes.

 

Coverage for Skilled Nursing Facility Care

Medicare Advantage plans offer coverage for stays in skilled nursing facilities. However, coverage for skilled nursing facility care depends on several factors, such as:

  • Collaborating with your doctor, healthcare providers, social workers, and family to identify the facility that best meets your needs.

 

  • Skilled nursing facility and nursing home stays are covered for up to 100 days.

 

  • Beyond 20 days, plans require coinsurance.

 

  • Beyond that, residents must cover expenses independently.

 

It’s important to note that Medicare Advantage plans must provide, at least, the same benefits as traditional Medicare, including up to 100 days of skilled nursing home care annually. However, some Medicare Advantage plans may limit coverage for skilled nursing or rehab services, leading to a shorter length of stay at the facility and reduced coverage for rehabilitation therapy and other services.

 

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 limitations on coverage for skilled nursing or rehab services, resulting in a shorter length of stay at the facility and reduced coverage for rehabilitation therapy and other services.

The required level of care significantly influences the coverage provided by Medicare Advantage for skilled nursing facilities. Adequate documentation must be submitted to verify that skilled care is necessary, and prior authorization may be required for certain treatments. Additionally, Medicare Advantage may provide coverage for:

  • Adult day care services

 

  • Installation of shower grips and toilet rails

 

  • Wheelchair ramps

 

  • Wider door openings

Comparing Traditional Medicare and Medicare Advantage

 

Do Medicare Advantage Plans Cover Skilled Nursing Facilities?, Comparing Traditional Medicare and Medicare Advantage

 

Understanding the differences between traditional Medicare and Medicare Advantage is key to making a sound decision about your healthcare coverage. Both options have their advantages and disadvantages, so let’s compare the two in terms of coverage and benefits.

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, providing additional benefits beyond what is covered by traditional Medicare.

Now, we should examine the coverage traditional Medicare provides for skilled nursing facilities and the pros and cons of both traditional Medicare and Medicare Advantage.

 

Traditional Medicare Coverage

Traditional Medicare provides coverage for a semi-private room and meals, skilled nursing care delivered by nursing staff, and rehabilitation services, including 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 covers a semi-private room and meals, skilled nursing care provided by qualified staff, and rehabilitation services, including physical therapy, for skilled nursing facilities. Traditional Medicare offers coverage for stays in a skilled nursing facility for the initial 20 days and covers the cost of medications in skilled nursing facilities.

While traditional Medicare provides basic coverage for skilled nursing facilities, it has some limitations compared to Medicare Advantage plans. Now we should examine the pros and cons of choosing traditional Medicare as opposed to Medicare Advantage.

 

Advantages and Disadvantages

The advantages of selecting traditional Medicare 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 offers the convenience of having all your healthcare needs managed by one plan, potentially 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 benefits and drawbacks of each option before deciding.

Having compared traditional Medicare and Medicare Advantage, we must examine in detail the additional benefits offered by Medicare Advantage plans.

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Additional Benefits of Medicare Advantage

 

Do Medicare Advantage Plans Cover Skilled Nursing Facilities?, Additional Benefits of Medicare Advantage

 

Medicare Advantage plans are known for offering additional benefits beyond what is included in Original Medicare. These benefits can make a significant difference in the quality of care and overall healthcare experience for enrollees.

Some of the extra perks that come with Medicare Advantage plans include:

  • Prescription drug coverage

 

  • Dental coverage

 

  • Vision coverage

 

  • Hearing coverage

 

  • Fitness and wellness programs

 

  • Transportation services

 

  • Over-the-counter allowances

 

  • Nurse helpline services

 

These additional benefits, as reported by Kaiser Health News, can help enhance the healthcare coverage and support for Medicare Advantage plan members.

From prescription drug coverage to in-home support services, Medicare Advantage plans offer a variety of benefits to cater to the diverse needs of their enrollees. Keep reading to learn more about prescription drug coverage and in-home support services offered by some Medicare Advantage plans.

 

Prescription Drug Coverage

Most Medicare Advantage plans provide prescription drug coverage through Medicare Part D. The difference between Medicare Advantage prescription drug coverage and standalone Medicare Part D plans lies in the fact that Medicare Advantage plans provide additional benefits beyond prescription drugs, such as dental, vision, and hearing coverage.

It is important to note that exceptions or limitations may exist in the prescription drug coverage provided by Medicare Advantage plans, and plan sponsors may consider granting exceptions requests for medically necessary drugs.

The expenses associated with prescription drug coverage in Medicare Advantage plans may include:

  • A monthly premium

 

  • A yearly deductible

 

  • Copayments or coinsurance

 

  • Costs in the coverage gap

 

  • Costs if you qualify for Extra Help

 

Understanding the costs and coverage of prescription drug benefits is essential when selecting a Medicare Advantage plan.

 

In-Home Support Services

Medicare Advantage plans provide a range of in-home support services, including:

  • Primary and preventive care

 

  • Urgent and complex care at home

 

  • Home health services are provided by licensed professionals like skilled nurses and therapists.

 

  • Personal home care

 

Certain Medicare Advantage plans provide supplemental benefits that include in-home care, but not all plans provide this coverage. It is imperative to review the details of your particular Medicare Advantage plan to ascertain if it covers in-home support services.

Beneficiaries utilizing in-home support services from Medicare Advantage have reported positive experiences, finding these services beneficial in permitting them to receive care in the comfort of their own homes and preserve their autonomy.

Family caregivers of Medicare beneficiaries have also expressed gratitude for the support provided by in-home services. These services have been demonstrated to decrease hospitalizations and elevate overall care satisfaction for beneficiaries.

Navigating Costs and Finding the Right Plan

 

Do Medicare Advantage Plans Cover Skilled Nursing Facilities?, Navigating Costs and Finding the Right Plan

 

Selecting the appropriate Medicare Advantage plan is a pivotal decision that can profoundly affect your healthcare experience and overall well-being. Understanding the costs linked with various plans and balancing them against the coverage and benefits they provide is key.

By doing so, you can make an informed choice that meets your unique needs.

This section will guide you in managing costs and finding the most suitable Medicare Advantage plan for you. We’ll discuss out-of-pocket costs and offer tips for choosing a plan that best suits your individual requirements.

 

Out-of-Pocket Costs

The out-of-pocket costs associated with Medicare Advantage plans can vary. Here are some typical cost-sharing elements:

  • Premiums

 

  • Deductibles

 

  • Co-payments

 

  • Coinsurance

 

The average out-of-pocket limit is typically around $4,835 for in-network services and $8,659 for both in-network and out-of-network services.

For 2023, the out-of-pocket maximum for Medicare Advantage plans is anticipated to reach $8,300 for in-network services and $12,450 for both in-network and out-of-network services, reflecting the rising Medicare costs.

Deductibles in Medicare Advantage plans operate by requiring you to pay a predetermined amount out-of-pocket before your plan begins to cover the expenses of your medical services or prescription drugs.

In 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 benefits, coverage, and costs of the plan options available to you is necessary. Compare the coverage and costs of different plans to ensure you obtain the most advantageous outcome from your Medicare plan.

Some of the highest-rated Medicare Advantage plans include:

  • Humana

 

  • Blue Cross Blue Shield

 

  • Aetna

 

  • UnitedHealthcare

 

  • Cigna

 

  • Anthem

 

These plans are highly rated due to their low-cost availability, comprehensive coverage, and expansive provider networks.

The Medicare Advantage plan network has an influence on the selection of a plan by limiting the physicians, hospitals, and other care providers from which enrollees can 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 pay higher co-pay and co-insurance amounts when you see out-of-network providers. Remember to weigh the benefits and drawbacks of each option before deciding.

Long-Term Care and Medicare Advantage

 

Do Medicare Advantage Plans Cover Skilled Nursing Facilities?, Long-Term Care and Medicare Advantage

 

Long-term care is a major concern for many individuals, and comprehending the scope of coverage provided by Medicare Advantage plans is key.

In this section, we explore long-term care coverage under Medicare Advantage plans and discuss alternative options for long-term care coverage outside of Medicare Advantage plans.

Although Medicare Advantage plans 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, among other factors.

Keep reading to learn more about the coverage for long-term care provided by Medicare Advantage plans and alternative options for long-term care.

 

Coverage for Long-Term Care

Medicare Advantage plans provide a range of services and support to assist individuals with everyday activities, including both medical and non-medical care for those who are unable to perform basic activities of daily living.

They may provide coverage for certain long-term care services, including:

  • Stays in a skilled nursing facility.

 

  • Hospice care

 

  • Respite care

 

  • Eligible home health care

 

However, Medicare Advantage plans typically do not cover larger expenses associated with long-term care, such as room and board costs.

Coverage for long-term care in Medicare Advantage is similar to traditional Medicare, offering the same coverage, including up to 100 days of skilled nursing home care. However, general long-term care in nursing homes is not typically covered by Medicare Advantage plans.

 

Alternative Options for Long-Term Care

In addition to Medicare Advantage, there are 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.

Utilizing life insurance for long-term care offers benefits such as safeguarding assets, a range of options to meet your requirements and budget, and potential tax deductions for premiums.

However, there are also disadvantages, such as expenses and price inconsistencies, as well as the possibility of paying premiums for years without utilizing the coverage.

Annuities can be employed to leverage long-term care costs in the following ways:

  • Adding a long-term care rider to provide benefits for long-term care expenses

 

  • Distributing taxable gains into tax-free benefits for long-term care

 

  • Utilizing a 1035 exchange to allocate a portion of annuity funds to cover long-term care expenses while preserving retirement income.

Summary

In conclusion, understanding the intricacies of Medicare Advantage plans and their coverage for skilled nursing facilities is essential for making informed healthcare choices. We’ve delved into the basics of Medicare Advantage plans, compared them to traditional Medicare, examined additional benefits, and provided guidance on navigating costs and finding the right plan for you.

Armed with this knowledge, you are now better equipped to make a well-informed decision about your healthcare coverage.

Remember to weigh the pros and cons of each option and consider your unique needs and preferences when selecting a plan, ensuring you receive the best possible care and support throughout your healthcare journey.

 

Frequently Asked Questions

 

→  Why do nursing homes not like Medicare Advantage plans?

SNFs don’t like Medicare Advantage plans due to their prior authorization requirements, limited lengths of stay and lower reimbursement rates.

 

→  How many days will Medicare pay 100% of the covered costs of care in a skilled nursing care facility?

Medicare covers up to 100 days of care in a skilled nursing facility, with the first 20 days covered at 100%. Eligibility and costs must be met during the benefit period.

 

→  What will Medicare cover up to of a skilled nursing facility?

Medicare covers up to 100 days of care in a skilled nursing facility (SNF) each benefit period. If you need more than 100 days of SNF care in a benefit period, you will have to pay out of pocket and the facility is not required to provide written notice if care is ending due to running out of days.

 

  Does Medicare Advantage cover skilled nursing facilities?

Yes, Medicare Advantage plans 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?

Traditional Medicare is a combination of Part A and Part B, whereas Medicare Advantage plans offer coverage for Part A and Part B plus additional benefits.

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Russell Noga
( Medicare Expert )

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.