The Centers for Medicare and Medicaid Services (CMS), which oversees Medicare, just issued a final rule designed to protect Medicare Advantage enrollees whose Medicare Advantage plans deny them needed care and help ensure providers are paid for the care they deliver. Josh Henreckson reports for McKnight’s on how the rule improves the process for appealing Medicare Advantage denials for rehab and skilled nursing services after hospitalization.
So that you’re up to speed: Insurers selling Medicare Advantage plans have repeatedly been found to inappropriately delay and deny necessary skilled nursing and rehabilitation care post-hospitalization. People in traditional Medicare get this care. Medicare covers up to 100 days of skilled nursing and rehab services for people who need daily skilled services and have been hospitalized for at least three days in the 30 days prior to admission to a facility.
People enrolled in Medicare Advantage plans struggle to get the rehab and skilled nursing care they need, not only because their plans deny them coverage but because they are on the hook for the cost of care that their Medicare Advantage plans won’t cover even when they appeal the decision. The CMS final rule ensures that these patients will not be liable for the cost of their treatment if they fail to appeal a denial of coverage while they are in the skilled nursing facility or rehab facility or if they do not win their appeal. Beginning in June, people in MA plans whose post-acute care is terminated will no longer be liable for the full cost of services after termination.
People who appeal these Medicare Advantage plan denials of skilled nursing or rehab care win more than eight in ten times. But the vast majority of people do not appeal. Often they do not know they can appeal. Or, they fear having to pay privately for the cost of their care if they do not win on appeal.
As important, the new CMS rule requires that an independent organization decide fast appeals for people in skilled nursing and rehab facilities. The Quality Improvement Organization and not the Medicare Advantage plans will decide these appeals
And, if people continue their care after their Medicare Advantage plan terminates their post-acute coverage and do not appeal at that time, they will now have the right to appeal after they leave the skilled nursing or rehab facility.
The final rule also helps skilled nursing and rehab facilities. They have been struggling because Medicare Advantage plans fail to pay them even when these plans’ have inappropriately denied their patients needed care. Without an independent review agency, there’s no reason for providers to believe that care denials will be overturned; the insurers have no incentive to reverse their original decision.
Here’s more from Just Care:
- More hospitalized Medicare patients will qualify for nursing home care
- UnitedHealth’s denials of critical rehab services is under investigation
- Humana sued for inappropriate Medicare Advantage care denials
- OIG finds widespread inappropriate care denials in Medicare Advantage
- Need skilled nursing care? Medicare Advantage insurers often won’t cover it
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