PART A — Hospital Insurance
- Inpatient Hospital: Semi-private room, meals, nursing, meds during admitted stay. Requires formal inpatient admission order.
- Skilled Nursing Facility: After qualifying 3-day inpatient stay.
- Home Health: Intermittent skilled nursing/PT/OT at home. Patient must be homebound.
- Hospice: Palliative care for terminal illness (6-month prognosis). Must waive curative treatment.
| SNF Days 1–20 | $0 |
| SNF Days 21–100 | $200/day |
| SNF Day 101+ | 100% patient |
⚠ Observation Status: Does NOT count toward 3-day inpatient rule. #1 SNF admission error.
PART B — Medical Insurance
- Covers: Physician & outpatient services, preventive care, DME, mental health (outpatient), ambulance, lab tests
- Does NOT cover: Custodial care, long-term nursing home, dental, vision, hearing aids
| Standard Premium | $174.70/mo |
| Annual Deductible | $240 |
| Coinsurance | 20% |
| Out-of-Pocket Max | None |
⚠ No cap: 20% coinsurance with no out-of-pocket maximum adds up fast.
PART C — Medicare Advantage
| Original Medicare | Medicare Advantage |
|---|
| Prior Auth | Rarely needed | Often required |
| Network | Any Medicare provider | Restrictions may apply |
| Benefits | Uniform national rules | Vary by plan & year |
| OOP Max | None | Annual cap |
| SNF Rules | Predictable | Plan-specific criteria |
⚠ Always verify: Original Medicare vs. Medicare Advantage — before admission.
PART D — Prescription Drugs
DeductibleFull cost
Up to $545
Initial CoveragePlan pays ~75%
Until $5,030
Catastrophic5% or small copay
No upper limit
- Discharge planning: Verify formulary before prescribing discharge meds
- Extra Help: Low-income subsidy eliminates/reduces copays — screen all patients
- MA Part D: Different formularies than standalone plans
📋 Case Study: When SNF Coverage Fails
Day 1Mrs. J, 74, admitted with hip fracture. Placed "under observation."
Day 3Changed to inpatient — only 1 qualifying day logged.
Day 5Discharged to SNF. Verified "hospital stay" but not inpatient status.
Day 12Part A claim denied — 3-day rule not met. Patient owes $200+/day.
Lesson: Verify 3 consecutive inpatient days (not observation) before SNF placement. A pre-admission Medicare checklist catches this.