Nursing Home Surprise: Advantage Plans May Shorten Stays to Less Time Than Medicare Covers

After 11 days in a St. Paul, Minnesota, skilled nursing facility recuperating from a fall, Paula Christopherson, 97, was told by her insurer that she should return home.

But instead of being relieved, Christopherson and her daughter were worried because her medical team said she wasn’t well enough to leave.

“This seems unethical,” said daughter Amy Loomis, who feared what would happen if the Medicare Advantage plan, run by UnitedHealthcare, ended coverage for her mother’s nursing home care. The facility gave Christopherson a choice: pay several thousand dollars to stay, appeal the company’s decision, or go home.

Health care providers, nursing home representatives, and advocates for residents say Medicare Advantage plans are increasingly ending members’ coverage for nursing home and rehabilitation services before patients are healthy enough to go home.

Half of the nearly 65 million people with Medicare are enrolled in the private health plans called Medicare Advantage, an alternative to the traditional government program. The plans must cover — at a minimum — the same benefits as traditional Medicare, including up to 100 days of skilled nursing home care every year.

But the private plans have leeway when deciding how much nursing home care a patient needs.

“In traditional Medicare, the medical professionals at the facility decide when someone is safe to go home,” said Eric Krupa, an attorney at the Center for Medicare Advocacy, a nonprofit law group that advises beneficiaries. “In Medicare Advantage, the plan decides.”

Mairead Painter, a vice president of the National Association of State Long-Term Care Ombudsman Programs who directs Connecticut’s office, said, “People are going to the nursing home, and then very quickly getting a denial, and then told to appeal, which adds to their stress when they’re already trying to recuperate.”

The federal government pays Medicare Advantage plans a monthly amount for each enrollee, regardless of how much care that person needs. This raises “the potential incentive for insurers to deny access to services and payment in an attempt to increase profits,” according to an April analysis by the Department of Health and Human Services’ inspector general. Investigators found that nursing home coverage was among the most frequently denied services by the private plans and often would have been covered under traditional Medicare.

The federal Centers for Medicare & Medicaid Services recently signaled its interest in cracking down on unwarranted denials of members’ coverage. In August, it asked for public feedback on how to prevent Advantage plans from limiting “access to medically necessary care.”

 

Source Link

Recommended Articles

AI in Healthcare: Calls for Stricter Standards Amid OpenAI Leadership Shuffle

Recent disruptions in OpenAI’s top brass have sparked intense dialogue within the healthcare sector, emphasizing the urgent need for robust standards governing the implementation of generative AI technologies. With Microsoft recruiting former OpenAI executives Sam Altman and Greg Brockman, concerns are growing that few corporations may soon dictate the trajectory of healthcare AI, potentially molding ...

Read More

2024 FSA, HSA, and HDHP Plan Limits

A health Flexible Spending Account (FSA) is an employer-sponsored benefit that allows eligible employees to save pre-tax dollars to pay for qualified medical expenses. Employees can elect a specific dollar amount, up to a certain limit, to set aside annually.

Read More

Proposals On PBMs And Medical Devices Advanced By House Subcommittee

The House Committee on Energy and Commerce health subcommittee pushed forward 21 proposals on Tuesday, some of which will restrict the power of pharmacy benefit managers (PBMs). Democrats supported many of the proposals put forward by Republicans, including legislation reining in PBMs that had support from 60 organizations representing patients, providers, pharmacists, small businesses and ...

Read More

CMS Tightening Network Adequacy Standards For Exchange Plans

Beginning in 2025, health plans sold in state-run insurance exchanges would be required to meet time and distance standards that are at least as adequate as mandated on federal marketplaces, according to a rule released by the Centers for Medicare & Medicaid Services (CMS) on Wednesday. Time and distance standards would be calculated at the ...

Read More
arrowcaret-downclosefacebook-squarehamburgerinstagram-squarelinkedin-squarepauseplaytwitter-squareyoutube-square