Employer Medicare Advantage with Medicaid

Understanding Employer Medicare Advantage + Medicaid

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.

What is Medicaid?

Medicaid is a state and federally funded program that helps individuals with limited income and resources pay for healthcare costs. Medicaid often covers expenses Medicare doesn’t, such as deductibles, copays, and long-term care services.

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: $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. 

• 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

• 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 check that all services and equipment are covered under your plan. Your length of stay at the facility is determined by your plan. 
• You may benefit from considering the options below, as they offer more benefits and coverage. *

• 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 in the hospital.
  • 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: $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. 

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

• Next Steps:

• • Enroll in a Medicare Part D drug plan to disenroll from your Medicare Advantage Plus plan. 
  • Medications will be covered by your Part D drug plan post your skilled nursing care stay. 
    • Out-of-pocket costs will be covered by the federal ExtraHelp program (through your Medicaid qualification).

• Switch to Dual Medicare Advantage*

1. • 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: Dental, vision, OTC (Over-the-counter) spending benefits and more. 
     • 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. 
   • 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. 

*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.

**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.