Different Types of Nursing and Your Medicare Coverage

Whether you’re in a doctor’s office, the hospital, or a rehabilitation facility, you will likely receive nursing care. Nurses provide many different types of care and work in a variety of medical settings. It’s helpful to know what patient care nurses provide. A patient can receive different levels of care depending on the nurse’s license and training. If you have Medicare coverage, most of your care will mainly be what is called Medicare skilled nursing.

What are the Different Types of Nursing Care?
Just like most professions, nurses have special training that teaches them how to care for patients. There are levels of training, college degrees, and licenses that nurses must receive in order to practice. And like different kinds of doctors, nurses sometimes have a specialized field. Below is an overview of the levels of training, licenses, and care they provide.

Licensed Practical Nurse (LPN): An LPN is a nurse who works under the supervision of registered nurses and doctors. LPNs often assist the registered nurses. They must complete a one year training program, which is often through vocational schools and community colleges. The nurses then have to take a test to be licensed by the state.

LPN’s take your blood pressure and other vital signs, give shots, collect samples like blood for testing, and provide general bedside care. LPNs spend time with patients and assist with daily care, including bathing and dressing. They work closely with registered nurses and other care providers. LPNs also work in many different settings, including doctor’s offices, skilled nursing facilities, and home health care.

Registered Nurse (RN): An RN must complete training either in a four-year bachelor’s degree college program, a two-year associate’s degree program, or graduate from a nursing program. They must pass a state licensing exam before they can treat patients.

RNs work in many settings. Because they have a higher level of training than an LPN, they are able to care for patients without direct supervision in more situations than LPNs. They will monitor your medications, start and check IVs, and perform many other medical procedures, but a doctor must “sign off” to show that he is overseeing the patient’s care. Many RNs will specialize in one area, like helping doctors deliver babies.

Nursing and Medicare Coverage
When you look at what your Medicare insurance covers, you’ll often see the words, “skilled nursing.” This is a term that is used to describe the level of nursing care that your Medicare insurance will pay for. Most often, you’ll see it when they talk about “skilled nursing facilities.” This is where patients receive skilled nursing services under the different parts of Medicare. Only registered nurses are considered “skilled nursing.”

Medicare Part A

Inpatient. As you may know, Part A of your Medicare coverage (if you have Original Medicare) pays for most of your care when you are hospitalized. Coverage includes care that you receive from hospital nursing staff, as long as they are registered nurses.Rehabilitation. Part A also pays for most of your care while in a “skilled nursing facility.” This is a rehabilitation facility that you attend if you need additional recovery care after your hospital stay. The nurses will ensure that you receive your medications, care for your wound if you’ve had surgery or an injury, and communicate with other medical staff, especially your doctor.

Note: A skilled nursing or rehab facility is sometimes also called a “nursing home.” The care you receive in a nursing home or skilled nursing facility that isn’t solely to continue recovering after a hospital stay is not usually covered by Medicare.

Home Health Care Services. When you return home either from your hospital stay or rehab, you can receive home health services. Under a doctor’s care, you will receive skilled nursing care by nurses who come to your home to monitor your recovery. These nurses work through a Medicare-certified home health agency. They will make sure that you take your medications and are healing properly.Hospice Care. If you are terminally ill and you, your family, and your doctor have decided to stop treatment and need palliative (comfort) care, you will receive most of these services through Medicare coverage. Typically, you will receive your care at home. Nurses will make home visits to administer pain medications and monitor your condition.

The Role of Skilled Nursing in Your Care
Nurses are key players to help you recover from illness, surgery, injury, or make your end-of-life more comfortable when you choose hospice care. Of all the members of your health care provider “team,” you will probably have the most contact with nurses. And since they communicate information about your recovery to doctors and other necessary people, it’s important to talk to them about any problems you might be having. Don’t be afraid to ask questions if you don’t understand something about a medicine or your care. If the nurse doesn’t know the answer, she will find out or ask the doctor.

Note: The information here is for Original Medicare coverage; if you have a Medicare Advantage plan and/or a Medigap plan, different care may be covered. Please refer to your printed plan information or look online at www.medicare.gov.

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The Different Types of Medicare Advantage Plans

Often referred to as Medicare “Part C,” a Medicare Advantage Plan is an additional health plan choice offered to most people eligible for Original Medicare. The plans do not offer supplemental coverage but are instead a private company option to Original Medicare. Different Medicare Advantage Plans offer plan-specific Medicare benefits, so it is important to compare Medicare plans to find out which one is best suited for you.

All Medicare Advantage Plans provide Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) benefits, and provide coverage for emergency medical care and urgent care services. They are also required to cover all services covered by Original Medicare except hospice care, which Original Medicare covers for everyone on Medicare, regardless of plan choice. Most Medicare Advantage Plans offer Part D prescription coverage either as an included benefit or at an additional cost.

There are four main types of Medicare Advantage Plans: HMO health plans, PPO health plans, Private Fee-for-Service plans, and Special Needs plans. HMO Point-of-Service plans and Medical Savings Accounts plans are two additional but less common Medicare Advantage Plans that may be available to some people. To compare Medicare plans, you should focus on the benefits and coverage you most medically need. Since Medicare Advantage Plans are offered by private companies approved by Medicare, there are a number of differences between the plans, including: how much the different Medicare benefits cost; whether the plans offer extra vision, hearing, dental and/or wellness coverage; and the rules for obtaining services.

Health Maintenance Organization (HMO)
A Health Maintenance Organization (HMO) plan is a health care plan in which your primary care doctor provides referrals to any specialists you may medically need to see for particular services. If you do not follow the proper rules for services, you may have to pay the full costs of the specialist’s care yourself. Except under certain circumstances, you are typically not covered for services obtained outside of the plan’s network of Medicare providers. While the rules of an HMO health plan may be relatively restrictive compared to other plans, in many cases, the extra rules are offset by the plan’s lower costs. A slightly different and less common version of the HMO health plan is the HMO Point-of-Service plan. Unlike a traditional HMO health plan, a HMO Point-of-Service plan allows you to obtain services from an out-of-network provider at a higher out-of-pocket cost. This benefit can make the plan function more like a PPO.

Preferred Provider Organization (PPO)
With a Preferred Provider Organization (PPO) plan you can generally obtain health care from any doctor or hospital you want. If you use an out-of-network provider you will often be required to pay a higher portion of the provider’s fees. PPO health plans typically do not require a referral for care by a specialist. Compared to an HMO health plan, a PPO plan is much less restrictive. However, the monthly premium for a PPO plan is often higher than that of a more restrictive plan.

Private Fee-for-Service
A Private Fee-for-Services plan allows you to go to any Medicare-approved doctor or hospital that agrees to treat you and will accept the plan’s payment terms. You do not need to choose a primary care doctor and referrals are not required for treatment by specialists. However, not all Medicare providers accept the plan. With a Private Fee-for-Services plan, the plan decides how much you pay the provider for each service. Some plans may have a network of providers that have agreed to accept the plan’s payment terms.

Special Needs
A Special Needs plan is a health care plan much like an HMO health plan, but it has limited membership. Some plans may include only those people who live at a particular nursing home or may limit coverage to individuals with a particular medical condition. If you are eligible for a Special Needs plan, you typically must obtain health care services from in-network providers, and you must choose a primary care doctor. Except for certain services (such as yearly mammograms), your primary care doctor must give you a referral to see a specialist if you want the services to be covered under the plan.

Medical Savings Account (MSA)
A Medical Savings Account (MSA) plan is much less common than the other types of Medicare plans. In an MSA, a high deductible health plan is combined with a bank account. Medicare deposits a particular amount of money per year into the bank account and you are allowed to use the money to pay for any health-care-related expenses throughout the year. It should be noted, however, that the deposit made by Medicare is often less than the yearly deductible, which means that if you get sick or medically need care you will likely have to spend more than the amount originally deposited into the account.

How Do the Plans Differ?
A major disparity between Medicare Advantage Plans is how much you are required to pay for different medical services. Out of pocket costs will vary depending on the plan you choose. Some Medicare Advantage Plans charge a monthly premium on top of your monthly premium for Part B coverage. Yearly deductibles can vary significantly between plans, with some ranging from a few hundred to a few thousand dollars. When you compare Medicare plans, keep in mind the type of health services you medically need, how often you get them, and what the copayment or coinsurance amount for those services would be under the different plans.

As mentioned, different plans also have different rules for obtaining services. Some plans may require you to get a referral from your primary doctor if you want to see a specialist. In such cases, the absence of a referral may mean the services provided by the specialist will either not be covered by your plan or will require you to pay higher costs out-of-pocket. Also, with some plans, if you obtain services from an out-of-network provider your out-of-pocket costs may be higher and/or the plan may decline to cover the services. To find out more about the particular benefits and coverage options offered by a Medicare Advantage Plan, contact the plan and request a Summary of Benefits document.

The new health care law includes changes that will give new incentives to private companies who offer Medicare Advantage Plans to improve your quality of care. Different health plans may change their benefits to ensure better coordination of your care and provide more options for services. When you compare Medicare plans, you should keep these changes in mind. Additionally, the new law requires every plan to include an annual cap on how much you are required to pay out of pocket for Part A and Part B services. This is called your annual maximum out-of-pocket cost and it may vary between Medicare Advantage Plans.

For help comparing Medicare plans, you can contact your State Health Insurance Assistance Program or visit www.medicare.gov.

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