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Deep Dive

Original Medicare with Medicaid

Understanding Original Medicare + Medicaid in a

Skilled Nursing Facility (SNF)

What is Original Medicare?

Original Medicare is the federal government’s health insurance program for individuals aged 65 and older, and for some younger individuals with disabilities. It consists of:

  • 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.

Prescription Drug Coverage:
Part D (Prescription Drug Plan): A stand alone Medicare Prescription Drug Plan offered by a private insurance company. 

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.

Coverage for Skilled Nursing Facility Care:

  • Days 1–20: Fully covered by Medicare (no out-of-pocket costs).
  • 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. 

No Prior Authorization Required:
With Original Medicare, there are no prior authorization requirements for SNF admission or services.

Prescription Drugs:
All medications administered at the facility are covered by Medicare Part A. Medications will be covered by your Part D drug plan post your skilled nursing care stay. 

Your Options: 

  1. Stay with Original Medicare + Medicaid: You can continue with your current Original Medicare coverage (Parts A and B). This includes coverage for hospital stays, doctor visits, other medical services, and prescription drugs.
  2. Switch to a Different Plan
  • Prescription Drug Plan (Part D): If you have a current Part D plan that isn’t meeting your needs, you can use the SEP* to switch to a different plan that better suits you. With Medicare and Medicaid, your prescription drugs are covered under a Part D plan, with little to no out-of-pocket costs. 
  1. Enroll in a Dual Medicare Advantage Plan: 
    • You can enroll in a Dual Medicare Advantage plan during the SEP*, which will include prescription drug coverage (Part D).

*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.