Medicare Advantage plans are once again found to inappropriately deny enrollees fair access to nursing home care, reports Kimberly Marselis for McKnight’s Long-Term Care News. While Medicare Advantage enrollees theoretically should receive the same benefits as people in Traditional Medicare, insurers use algorithms to prevent their Medicare Advantage enrollees from receiving as much nursing home and rehab care as people in Traditional Medicare. Cutting people’s length of stay in nursing homes is one way the Medicare Advantage insurers reduce costs and maximize profits.
Put starkly, Medicare Advantage insurers cover their enrollees’ nursing home stays for an average of 26 days. Traditional Medicare, which is administered directly by the government, covers its enrollees’ nursing home stays for an average of between 35 and 44 days. The Medicare nursing home benefit is designed to cover up to 100 days in a nursing home, each benefit period, for people who require daily skilled nursing and/or therapy care. To qualify, people must have been hospitalized for at least three days as an inpatient in the 30 days prior to nursing home admission.
Before Medicare Advantage enrollees in nursing homes meet their functional goals, their insurers are claiming that they should be discharged. Not surprisingly, one company that contracts with Medicare to review nursing home appeals and ensure patient safety, a Quality Improvement Organization (QIO), finds that the vast majority of enrollee appeals challenging decisions to discharge them are from people in Medicare Advantage. More than nine in ten (93 percent) appeals are from people in Medicare Advantage, while fewer than one in ten (7 percent) are from people in Traditional Medicare.
In short, people in Medicare Advantage requiring nursing home care are much more likely to feel that their insurer is trying to get them out before they are ready to leave. The QIO overturned nearly half the Medicare Advantage plan discharge decisions.
In addition, people in Medicare Advantage requiring nursing home care tend to receive repeated notices of discharge, seemingly unrelated to their health status; rather, they are related to the number of days they are in a nursing home. The Medicare Advantage discharge notices fall at the same time, seemingly regardless of the patient’s condition. Clinical status should dictate the patient’s length of stay. Can the patient walk and transfer from the bed to a chair?
Clinical goals are set because when patients don’t meet them, they are more likely to fall and need long-term care. They are more likely to die prematurely. But, insurers benefit financially when they’re not covering the cost of nursing home care, and that’s their priority.
Only Traditional Medicare covers the care people need. Unlike Medicare Advantage insurers which are driven to cut costs, even when it hurts patients, Traditional Medicare puts the needs of its enrollees first.
Here’s more from Just Care:
- Medicare Advantage: Beware of inappropriate nursing home stay denials
- Medicare coverage of nursing home care is very limited
- Don’t trust Medicare nursing home star ratings
- Before choosing a nursing home, check out Nursing Home Inspect
- Traditional Medicare offers better home care benefits than Medicare Advantage
