Understanding Employer Medicare Advantage
in a Skilled Nursing Facility (SNF)
What is an Employer Medicare Advantage Plan?
An Employer Sponsored Medicare Advantage plan (also known as Part C) is a health insurance plan sponsored by a former employer or union. They are designed for retirees and may also offer coverage for spouses. It combines:
- Part A (Hospital Insurance): Covers inpatient hospital care, skilled nursing care, and some home health care.
- Part B (Medical Insurance): Covers doctor visits, therapies, and medical services.
- Additional Benefits: Many plans include extras like prescription drug coverage (Part D), vision, dental, and hearing.
Because Employer Medicare Advantage plans are managed by private insurers, they operate with specific coverage rules and provider networks.
- Prior Authorization Is Required
- Your plan requires prior approval for many services in the facility, including admission, therapies, tests, medical equipment and length of stay at the facility.
- Without prior authorization, services will be denied, and you will be responsible for the cost of care at the facility.
- Costs and Coverage
- Coverage for skilled nursing care follows Medicare’s basic structure:
- Days 1–20: Covered by your Employer Medicare Advantage plan, as long as your insurance approves your stay.
- Days 21–100: Should you be approved for continued stay past day 20, you may have a daily co-pay (amount varies by plan).
- After Day 100: You’re responsible for the full cost.
- Prescription Drug Coverage
- Most Employer Medicare Advantage plans include drug coverage. All medications administered at the facility are covered as long your insurance approves your stay.
Your Options:
- Stay with Your Employer Medicare Advantage Plan
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- Contact your employer’s benefits department to confirm how skilled nursing facility care is covered under your specific plan.
- Be aware of prior authorization requirements and possible copays. Check that all services and equipment are covered under your plan. Your length of stay at the facility is determined by your plan.
- Switch to Original Medicare*
- Contact Your Employer’s Benefits Department: Before making any changes, reach out to your employer’s benefits department to confirm if re-enrollment is possible and to understand the impact on your integrated pension benefits and spousal coverage.
- With Original Medicare:
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- Part A (Hospital Insurance): Covers inpatient hospital care, skilled nursing care, and some home health care. Deductibles and copays apply.
- Part B (Medical Insurance): Covers doctor visits, therapies, and medical services. Non-preventative services covered up to 80%.
- Prior authorizations are not required. With Original Medicare, there are no prior authorization requirements for all Medicare approved services including therapies, tests, medical equipment and length of stay at the Skilled Nursing Facility.
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- Original Medicare gives up to 100 days for skilled nursing care.
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- Length of stay is determined based on your medical needs and the interdisciplinary team at the facility.
- Days 1-20: Fully covered by Medicare.
- Days 21–100: $209.50 daily copay.
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- After Day 100: You’re responsible for the full cost.
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- All medications administered at the facility are covered by Medicare Part A.
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- Next Steps:
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- Enroll in a Medicare Part D drug plan to disenroll your Employer Medicare Advantage plan.
- Medications will be covered by your Part D drug plan post your skilled nursing care stay.
- Consider adding a Medicare Supplement plan to help with out-of-pocket costs.
*You qualify for a Special Enrollment Period (SEP) to make plan changes. Changes can be made for as long as you are in the facility and for an additional two months after the month you leave the facility.