Susan Jaffe writes for Kaiser Health News about the risk that your Medicare Advantage plan will inappropriately deny you the nursing home care you need. Because the government pays Medicare Advantage plans a flat upfront fee, they have a powerful financial incentive to keep you from getting the costly care you need. They profit more the less they spend on your care.
No one is monitoring in real time when and how Medicare Advantage plans delay and deny nursing home care, or any other care for that matter. The government pays Medicare Advantage plans to cover the same amount of medically necessary care as traditional Medicare covers. And, though the Medicare nursing home benefit is limited, it should cover as much as 100 days in a nursing home for people who have been hospitalized as an inpatient for at least three days in the 30 days prior to nursing home admission and who need daily skilled nursing or therapy services.
The Office of the Inspector General (OIG) reports that Medicare Advantage plans can and do stint on costly care, including nursing home care, even when your treating physician says it is medically necessary. And, the Centers for Medicare and Medicaid Services (CMS), the agency charged with overseeing Medicare, does not publicly identify the bad Medicare Advantage actors, let alone cancel contracts with those that engage in widespread inappropriate delays and denials of coverage, as some do.
In her story, Jaffe reports on a 97-year old woman in a nursing home whose Medicare Advantage plan told her it was ending nursing home coverage after only an 11-day stay. Her medical team disagreed with the decision, saying that she was not in good enough health to return home. She had taken a bad fall. Experts report that it has become increasingly common for Medicare Advantage plans to overrule the treatment preferences of patients and their doctors and deny care, without even seeing the patient.
The American Health Care Association has “significant concerns” about the behavior of Medicare Advantage plans. No question that people are better off in their homes when they are healthy and able to take care of themselves, as the Medicare Advantage plans argue. But, it’s unsafe to push vulnerable older adults out of a nursing home before they are in good enough shape to manage at home.
If your Medicare Advantage plan denies you skilled nursing facility or rehab care that your medical team says you need, you have the right to appeal. With a letter from the medical team explaining why care is medically reasonable and necessary and why you meet the eligibility requirements for skilled nursing facility or rehab benefits, there is a very high likelihood the Medicare Advantage plan will reverse its decision. And, if it does not do so, you can appeal to a higher level authority, where you are likely to succeed on appeal.
There is no cost to appealing a Medicare Advantage denial of coverage, and it’s easy. You will likely face bills from the nursing facility while your appeal is being decided. But, you can ignore the bills if you win your appeal, and you have a high likelihood of winning. The Medicare Advantage plan will have to pay. Unfortunately, your Medicare Advantage plan faces no penalty for inappropriate denials. So, it can continue to deny care inappropriately without any likely consequence.
Here’s more from Just Care:
- Data show Medicare Advantage covers less nursing, rehab, home health care
- Medicare coverage of nursing home care is very limited
- New study finds Medicare Advantage plan enrollees end up in lower quality nursing homes than people in traditional Medicare
- Don’t trust Medicare nursing home star ratings
- Roundup: Housing options for older adults
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