Original Medicare vs. Medicare Advantage: Why Does It Matter After a Hospital Stay?

Introduction

“My dad has Medicare.”

That sounds straightforward. But when your father is in the hospital or preparing to leave, one of the first questions the hospital case manager may ask is:

“Does he have Original Medicare or Medicare Advantage?”

The distinction matters.

Original Medicare and Medicare Advantage both provide Medicare coverage. But they can work differently when a patient needs care after a hospital stay.

The differences can affect which post-acute care providers are available, whether insurance authorization is required, and how continued care is approved.

Neither Original Medicare nor Medicare Advantage is always better.

They provide different ways of accessing healthcare. Which differences matter depends largely on what the patient needs.

You do not need to become a Medicare expert.

But understanding a few important differences can help you recognize your options and ask better questions.

First, Which Type of Medicare Do You Have?

Many people simply say:

“I have Medicare.”

They may not know whether they have Original Medicare or Medicare Advantage.

Original Medicare (OM) generally includes coverage for hospital care and outpatient care and is administered through the federal Medicare program.

OM does not include coverage for most outpatient medications. Medication coverage needs to be purchased separately.

Medicare Advantage (MA) provides Medicare benefits through a private insurance company approved by Medicare.

Most MA plans include medication coverage. Many also provide additional benefits such as dental, vision, or hearing coverage.

If you are unsure which type of Medicare you have, show your insurance cards to the hospital case manager.

Knowing which type you have can become especially important when planning care after hospitalization.

A Quick Comparison

OM and MA cover many of the same healthcare services, but they do not always provide access to those services in the same way.

These differences become especially important when a patient needs additional care after hospitalization.

Your Type of Medicare Can Affect the Care Options Available at Discharge

Consider an older adult who falls and comes to the emergency department.

The patient has an injury that does not require hospital treatment but has pain and difficulty walking.

From a medical standpoint, the patient does not need to remain in the hospital. From a functional standpoint, returning home may not be realistic.

A physical therapist evaluates the patient and recommends short-term rehabilitation at a skilled nursing facility.

If the patient has OM, the three-day inpatient-status hospital stay requirement may prevent Medicare coverage for skilled nursing facility care.

Some MA plans do not require the three-day hospital stay. If the patient meets the plan’s requirements, the MA plan may authorize admission directly to a skilled nursing facility.

This is one situation in which MA can provide an important option that may not be available through OM.

If your loved one needs skilled nursing facility care but does not have the three-day inpatient-status hospital stay required by OM, talk with the hospital case manager about what other care options may be available.

Acute Rehab May Be Another Option

For some OM beneficiaries who cannot access skilled nursing facility coverage because of the three-day requirement, acute inpatient rehabilitation, or acute rehab, may be another option.

Acute rehab and skilled nursing facility care are different levels of rehabilitation.

A skilled nursing facility provides nursing care and rehabilitation for patients who need continued assistance and therapy after hospitalization.

Acute rehab provides a higher level of therapy.

Not every patient who needs rehabilitation will be appropriate for acute rehab.

If the three-day requirement is creating a barrier to skilled nursing facility care, ask the hospital case manager whether acute rehab might be an appropriate option.

The case manager can work with the patient, family, therapists, doctors, and rehabilitation facilities to determine what options are appropriate and available.

Medicare Advantage May Require More Insurance Authorization

One of the most important differences between OM and MA appears after post-acute care is recommended.

MA plans may require prior authorization before services such as skilled nursing facility care, acute rehab, or home health can begin.

This means the healthcare provider sends information to the insurance company and requests approval for the recommended care.

After care begins, an MA plan may also conduct concurrent review. This means the insurance company reviews the patient’s progress and decides whether it will continue to authorize the care.

For example, an MA plan may authorize an initial skilled nursing facility stay and later decide whether additional days will be covered.

If continued care is not authorized, ask the facility to explain what happened and what options are available.

If you disagree with the decision, ask:

“What are my appeal rights, and what is the deadline?”

Original Medicare Usually Requires Less Ongoing Authorization

OM generally does not use the same prior authorization and concurrent review process for post-acute care.

The healthcare provider still needs to determine that the patient meets Medicare requirements and document the need for continued services.

But there usually is not an insurance company repeatedly authorizing additional groups of skilled nursing facility days or home health visits.

Once an OM beneficiary has access to appropriate post-acute care, this can make continued care more straightforward.

What About Home Health?

The same basic difference can affect home health.

With OM, home health agencies generally do not need repeated prospective authorization for additional groups of visits.

MA plans may require ongoing authorization for continued home health services.

If the home health agency believes additional visits are needed but the MA plan will not authorize them, ask the agency what it recommends.

Then call the insurance company directly and ask why continued services were not authorized and what options are available.

Medicare Advantage May Limit Which Providers You Can Use

OM generally provides a broader choice of post-acute care providers.

MA plans may restrict patients to skilled nursing facilities, acute rehab facilities, home health agencies, and other providers that participate with the plan.

When post-acute care is being arranged, ask the hospital case manager:

“Which of the available providers participate with my plan?”

Remember that MA plans differ. A facility that accepts one MA plan may not accept another.

Different Advantages at Different Times

The advantages and limitations of OM and MA depend on what the patient needs.

MA usually includes medication coverage and may provide additional benefits.

MA may also provide easier access to skilled nursing facility care when a patient needs that level of care but does not have OM’s required three-day inpatient-status hospital stay.

On the other hand, MA may require prior authorization and concurrent review of post-acute care and may limit which providers can be used.

OM’s three-day requirement can create a barrier to skilled nursing facility coverage for some patients.

But once an OM beneficiary has access to post-acute care, there is generally less ongoing insurance authorization.

Neither system is always better.

What matters is understanding how the type of Medicare you have affects the care you need.

Questions to Ask

If you or a loved one needs care after hospitalization, consider asking:

• Do I have Original Medicare or Medicare Advantage?
• What level of care is being recommended?
• Which providers are available with my coverage?
• Does the recommended care require insurance authorization?
• Has authorization been approved?
• If the OM three-day SNF requirement is a problem, are there other appropriate options?
• Will continued care require ongoing authorization?
• What are my options if continued care is not authorized?

You do not need to understand every Medicare rule.

You need to understand what care is being recommended and how the type of Medicare you have affects your options.

The Bottom Line

OM and MA both provide Medicare coverage.

But they can affect post-hospital care differently.

MA may provide access to skilled nursing facility care without OM’s three-day hospital stay requirement, but it may also require prior authorization, concurrent review, and use of participating providers.

OM can create a barrier to skilled nursing facility coverage because of the three-day requirement, but other appropriate rehabilitation options may be available.

Once post-acute care is established, OM generally involves less ongoing insurance authorization.

The type of Medicare matters.

But the starting point should always be:

“What care does the patient need?”

How HNav Can Help

Differences between OM and MA can become confusing when a patient suddenly needs additional care after hospitalization.

HNav helps patients and families understand what care is being recommended, how their Medicare coverage affects the available options, and what questions to ask.

Our goal is not to tell you whether OM or MA is better.

Our goal is to help you understand how the coverage you have affects the healthcare choices in front of you.