Dual Medicare Advantage

Understanding Your Dual Medicare Advantage Plan in a

Skilled Nursing Facility (SNF)

What Is a Dual Medicare Advantage Plan?

A Dual Medicare Advantage plan (also known as a Dual Special Needs Plan, or Part C) is a type of Medicare Advantage plan specifically designed for individuals with both Medicare and Medicaid. It combines:

• Part A (Hospital Insurance): Covers inpatient hospital care, skilled nursing care, hospice and some home health care.
• Part B (Medical Insurance): Covers doctor visits, outpatient services, therapies, and medical services.
• Medicare Part D: Includes prescription drug coverage.
• Medicaid Benefits: Additional financial assistance for premiums and co-pays.
• Additional Benefits: Many plans include dental, vision, OTC (Over-the-counter) spending benefits and more. 

Because Dual Medicare Advantage plans are managed by private insurers, they operate with specific coverage rules and provider networks.

1. 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.
2. Costs and Coverage
   • Coverage for skilled nursing care follows Medicare’s basic structure:
     • Days 1–20: Covered by your Dual Medicare Advantage plan
     • Days 21–100: $0 copay, provided you have Qualified Medicare Beneficiary (QMB) Medicaid or Nursing Home Medicaid.  
     • After Day 100: You’re responsible for the full cost, unless you have Nursing Home Medicaid. 
3. Prescription Drug Coverage
   • Dual Medicare Advantage plans include drug coverage. All medications administered at the facility are covered as long your insurance approves your stay. 

 Your Options: 

1. 1. Stay with Your Dual Medicare Advantage Plan 
      • Medicaid helps reduce costs, and your care is managed by the plan.
      • Be aware of prior authorization requirements and check that all services and equipment are covered under your plan. Your length of stay at the facility is determined by your plan. 
   2. Switch to Original Medicare + Medicaid* 
      • Part A (Hospital Insurance): Covers inpatient hospital care, skilled nursing care, hospice and some home health care. Deductibles and copays apply. Medicaid will cover the deductibles and copays.
      • Part B (Medical Insurance): Covers doctor visits, outpatient services, therapies, and medical services. Non-preventative services covered up to 80%. Medicaid will cover the remaining 20% coinsurance. 
      • Prior authorizations are not required. (For skilled nursing care/rehab and otherwise).
      • Original Medicare gives up to 100 days for skilled nursing care.
        • 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: Daily copay that is covered by Medicaid if one also is a Qualified Medicare Beneficiary (QMB). 
        • After Day 100: You’re responsible for the full cost, unless you have Nursing Home Medicaid. 

• All medications administered at the facility are covered by Medicare Part A. 

• Next Steps:

1. • • Enroll in a Medicare Part D drug plan to disenroll your Dual Medicare Advantage plan. 
     • Medications will be covered by your Part D drug plan post your skilled nursing care stay. 
       • Out-of-pocket costs may be covered by the federal ExtraHelp program (through your Medicaid qualification). Your Medicaid level will determine your medication copay. The maximum being $4.90 for generic medications, and $12.15 for brand-name medications. Those with higher level Medicaid may pay less or $0 for their medications. 

*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.