Did You Know? All Medicare Advantage Plans must offer the same benefits as Original Medicare but are allowed to have different costs and restrictions. Some may offer additional limited benefits such as vision or dental coverage. If you have Original Medicare, Part A determines coverage and costs of inpatient hospital care and skilled nursing facility care based on benefit periods. A benefit period begins the day you enter a hospital and ends when you have not received inpatient hospital or Medicare covered skilled care in a SNF for 60 consecutive days. If you go into the hospital or SNF after one benefit period has ended a new benefit period begins. YOU must pay the Part A deductible for each benefit period.
There are two common types of Medicare Advantage. There are health maintenance organizations (HMO's) and there are preferred provider organizations (PPO's). Usually HMO's only cover care from providers within their networks and if you go 'out of network' you are responsible for the full cost of your care. Referrals may be required to see specialists. If you have a PPO Advantage plan you will be paying the least if you stay within network but there is limited coverage for out of network providers; referrals are not required to see a specialist. This freedom is costly; generally PPO's charge higher premiums to join than HMO's. If you have a Medicare Advantage plan, it may have different rules for how it covers hospital and skilled nursing facility care. Contact your plan directly for answers.
Before signing up for any Advantage Program, check with your former employer .
How Does Hospital Admission Status Affect YOU? Medicare beneficiaries who are hospitalized in "observation status" may affect their coverage. Currently there is a 3 day inpatient stay required to qualify for full Medicare coverage of skilled nursing facility care. This means Medicare beneficiaries are being denied access to Medicare's skilled nursing facility benefit because acute care hospitals are increasingly classifying their patients as 'outpatients' receiving observation services. Don't let the label 'outpatient' fool you! Patients are called outpatients despite the fact that they may stay several days and nights in the hospital and receive both medical and nursing care! It will affect your coverage and responsibility for payment so it is imperative you ask in order to make an informed decision.
There is bipartisan support in Congress to fix this problem. Add your voice in calling on Congress to support the Improving Access to Medicare Coverage Act of 2015 (S843/HR1571). These bills would require that time spent in observation be counted toward meeting the three day prior inpatient stay that is necessary to qualify for coverage of skilled nursing facility services under Medicare.
Medicare, Hospice and YOU......There are very specific conditions where Medicare will help pay for your hospice care. There are more than 4 specific criteria. Check with Medicare directly or, if you have an Advantage Plan, contact them directly. If you meet the criteria, the hospice benefit is always covered under Original Medicare.