Understanding Original Medicare + Part D 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, hospice and some home health care.
- Part B (Medical Insurance): Covers doctor visits, outpatient services, 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.
No Prior Authorization 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.
Coverage for Skilled Nursing Facility 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 (no out-of-pocket costs).
- Days 21–100: Covered with a $209.50 daily copay. If you have a Medicare Supplement (Medigap) insurance plan, it will likely cover this co-pay.
- After Day 100: You’re responsible for the full cost.
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:
- Stay with Original Medicare + Prescription Drug Plan: You can continue with your current Original Medicare coverage (Parts A and B). This includes coverage for hospital stays, doctor visits, and other medical services.
- Add a Medicare Supplement Plan (Medigap): If you remain on Original Medicare, and do not already have a Supplement plan, you may purchase one to help cover out-of-pocket costs like deductibles, copays, and coinsurance.
- 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.
- Medicare Advantage Plan: You can switch to a 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.