When it comes to senior care payment options, you’ll likely come across the terms “managed care” and “Medicare.”

The good news: both are common and viable options, especially for short-term rehabilitation and skilled nursing services.

The challenge: They both have several nuances and differences in areas such as pre-approvals, length of stay and other key criteria that can impact care.

We’re here to save you hours of Googling, waiting on hold for answers, or your head spinning in confusion. Let’s break down the key details and differences between managed care and Medicare.

• Managed Care

  Managed care health plans are operated by private insurance companies that collaborate with a network of healthcare providers to coordinate and deliver services.

  The two main types of managed care are Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). HMOs require you to have a primary care doctor who manages care within the network. PPOs offer more flexibility by allowing you to see out-of-network providers, though at higher costs.

  Managed care plans tend to have lower upfront costs like premiums and deductibles, but have a more limited choice of providers and may require pre-approval for specific services. But its focus on care coordination through a primary care doctor can be very helpful in promoting preventative care.

• Traditional Medicare

  Medicare is a federal health insurance program for individuals aged 65 and older, though certain younger individuals with disabilities also qualify. It’s divided into different parts:

  • Medicare Part A covers hospital stays, skilled nursing facility care, hospice care, and select home care services.
  • Medicare Part B covers outpatient services and medical supplies, including doctor visits, preventive care, and durable medical equipment.
  • Medicare Part D pertains to prescription drug coverage.

  Medicare traditionally has higher upfront costs like premiums and deductibles, but it offers lower copays for services. There are no networks or pre-approvals needed. Additionally, Medicare recipients can purchase supplemental Medigap plans to cover out-of-pocket costs and Part D prescription drug plans.

  Unlike managed care, you have more flexibility in choosing healthcare providers, including skilled nursing facilities and long-term care centers (as long as they accept Medicare).

Medicare & Managed Care – The Key Differences

	Traditional Medicare	Managed Care
Administration	Federal government	Private insurance companies
Provider choice	Wide choice of providers	Limited to in-network providers
Scope of Coverage	Standard, but may have limits related to long-term care	Determined by specific plan or network of providers
Long-term care coverage	Limited, usually for short periods	Coverage may vary among plans
Cost structure	Higher upfront costs (premiums and deductibles), but lower copays	Lower upfront costs and higher copays
Pre-approvals	Not required	Required for services and hospital admissions
Referrals	Not required	Some plans may require referrals
Care coordination	More flexibility in choosing providers	Primary care physician (PCP) required for referrals

Considerations in Skilled Nursing and Long-Term Care

Let’s dive into how managed care and Medicare impact senior settings:

• Pre-approvals & Pre-authorization

  Managed care plans require pre-approval from your insurance provider before admission to a skilled nursing facility. This can sometimes lead to delays, particularly for those seeking short-term rehabilitation. It’s important to work closely with your primary care physician and the managed care plan to ensure all necessary documentation is provided promptly.

  Medicare under Part A doesn’t mandate pre-approval, but does conduct regular reviews to ensure that skilled care is medically necessary.

• Length of Stay

  Managed care plans may impose limitations on the number of days they will cover for short term. They closely manage the length of stay, authorizing coverage only for the duration deemed medically necessary.

  Medicare offers more leeway based on assessed medical needs. Under Medicare Part A, it covers up to 100 days of skilled nursing facility care after a qualifying hospital stay. Stays exceeding 100 days require justification to continue coverage.

• Long-Term Care

  Neither managed care nor Medicare covers custodial long-term care. However, certain managed care plans may cover restorative services such as physical, occupational, and speech therapy within long-term care settings.

  Medicare covers medically necessary therapy services in long-term care, including rehabilitative therapy in nursing homes, as long as they’re deemed reasonable and necessary. This can be particularly beneficial for those who require ongoing therapy to maintain or improve their functional abilities.

  Managed care plans often have set limits on the number of therapy sessions or dollars per day/week. Additional therapy may require approval.

Choosing Quality Senior Care with Catholic Charities NH

Here at Catholic Charities NH, we offer a holistic approach to senior care that caters to diverse payment options, including many managed care plans as well as traditional Medicare, ensuring that residents receive the care they deserve, no matter their financial situation.

Learn more about our person-centered, compassionate senior care.