Medicare managed care plans offer the same services as original Medicare, and sometimes additional benefits. This article will offer an overview of Medicare-managed care plans and explain how they relate to nursing home abuse.

Key Takeaways

• A Medicare managed care plan is an alternative to Medicare Parts A and B offered by private companies, usually offering additional benefits for services that original Medicare does not cover
• The types of Medicare-managed care plans include HMOs, PPOs, HMO-POSs, PFFSs, and SNPs.
• Anybody who is eligible for Medicare Parts A and B is eligible for a Medicare managed care plan
• Unlike Medicare Part A, a Medicare-managed care plan may cover long-term stays in nursing homes
• All nursing home patients are cautioned to be aware of the risk of nursing home abuse

What Is a Medicare Managed Care Plan?

Medicare managed care plans, also called Medicare Part C or Medicare Advantage, are an alternative to original Medicare Parts A and B offered by private companies that have a contract with Medicare. Companies offering Medicare managed care plans need to follow set rules and regulations, such as covering all the same services as original Medicare. 

Most managed care plans offer additional benefits for services that original Medicare does not include, such as vision, dental, hearing, or prescription drug coverage (Medicare Part D). 

Types of Medicare Managed Care Plans

The types of Medicare managed care plans are similar to the other insurance offerings on the marketplace. These include:

• Health maintenance organization (HMO) - This is a common health plan that works with a network, covering care provided by health care providers within the network.
• Preferred provider organization (PPO) - PPOs also work with networks but allow members to see providers who aren’t part of the network for a higher out-of-pocket cost.
• Health maintenance organization point of service (HMO-POS) - An HMO-POS plan works with a network but allows members to get certain services from out-of-network providers at a higher cost.
• Private fee-for-service (PFFS) - This is a less common type of managed care plan that does not work with networks. Instead, members can see any doctor who contracts with Medicare.
• Special needs plan (SNP) - This managed care plan is for people with limited incomes who manage certain conditions or live in long-term care facilities. 

Who Is Eligible for a Medicare Managed Care Plan?

In order to be eligible for a managed care plan, a person must be enrolled in both Medicare Part A and B. To be eligible for Medicare Part A and B, a person must meet at least one of the following criteria:

• Be age 65 or older
• Have a disability and receive a minimum of 24 months of Social Security Disability Insurance (SSDI)
• Had a diagnosis of end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS)

Medicare Managed Care Plans and Nursing Home Coverage

Original Medicare Part A only covers short-term stays in skilled nursing facilities. It does not cover a long-term stay at a nursing home. Patients requiring long-term stay may need additional health insurance coverage to help pay the cost, such as from a Medicare managed care plan.

Medicare Managed Care Plans and Nursing Home Abuse

No matter the insurance coverage or the length of the stay, all nursing home residents should be aware of the risk of nursing home abuse, or the intentional or unintentional harm of a nursing home patient by nursing home staff. If you or a loved one have experienced nursing home abuse, it is important to contact the relevant authorities immediately. 

Victims of nursing home abuse may be eligible for compensation for their pain and suffering. For a review of your case, contact a nursing home abuse attorney.