Tag: Skilled nursing

Medicare Advantage enrollees denied post-acute care get better protections
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:
April 8, 2024
Need skilled nursing care? Medicare Advantage insurers often won’t cover it
Insurers offering Medicare Advantage plans are causing nursing homes to lose money at a rapid pace, reports Amy Stulick for Skilled Nursing News. These insurers are not only paying Medicare-nursing homes less than the traditional Medicare rate, they are too often not covering enrollees’ care in nursing homes, even when they are required to do so. If our government does not step in to insist that insurers pay nursing homes the Medicare rate, there may be no skilled nursing facility care available to Medicare patients.

Today, Medicare covers care in skilled nursing facilities in limited situations. To qualify for Medicare skilled nursing care, patients must need daily skilled nursing or therapy services and receive these services in a Medicare-certified skilled nurse facility. Moreover, they must be hospitalized for at least three days in the 30 days prior to admission to a skilled nursing facility. So long as they qualify, Medicare covers up to 100 days of care per benefit period.

But, insurers offering Medicare Advantage plans don’t like to spend the money they receive to cover Medicare services. Every service they do not cover is money in their pockets. So, people in Medicare Advantage plans often do not get nursing home care or get very limited nursing home care or get poor quality nursing home care.

Marc Zimmet, the president of Zimmet Healthcare says that nursing homes are losing $274.9 million for every one percent increase in Medicare Advantage enrollment. Traditional Medicare pays about 87 percent more ($841) for nursing home care than insurers offering Medicare Advantage ($448). Not surprisingly, Medicare Advantage enrollees not only get less nursing home care than traditional Medicare enrollees, they are forced to use lower quality nursing homes.

People enrolled in Medicare Advantage need to recognize that they are taking a big risk with their health. They can’t count on getting high quality physician and hospital care; they can’t count on continuity of care; they can’t count on getting needed care. Yes, it is true that some people do perfectly well in Medicare Advantage; it’s also true that hundreds of thousands, if not millions, experience serious deterioration of their health and tens of thousands die needlessly. With Medicare Advantage, you are always playing the odds; you could end up in a killer plan.

Here’s more from Just Care:
April 1, 2024
Data show Medicare Advantage covers less nursing, rehab, home health care
The Kaiser Family Foundation just released a new study looking at more than 60 past studies of Medicare Advantage. The takeaway is familiar: People with few health care needs fare well in Medicare Advantage. People with costly and complex health care needs receive less post-acute care: they get less nursing, rehab and home health care, often from lower quality providers, in Medicare Advantage. When deciding whether to enroll in Medicare Advantage, keep in mind that health insurance should meet your unforeseeable health care needs down the road.

The 62 studies, conducted since 2016, focused on people’s experiences affording health care, using health care and getting quality care in traditional Medicare and Medicare Advantage. The authors found that people in Medicare Advantage were less likely than traditional Medicare enrollees not only to use post-acute services but to get treatment in hospitals, skilled nursing facilities, and home health agencies which have the highest quality ratings. The study could not determine whether less use of post-acute care jeopardized health outcomes of study participants.

We already know from the HHS Office of the Inspector General that Medicare Advantage plans use prior authorization requirements for post-acute services that inappropriately delay and deny care their enrollees need. These “widespread” inappropriate delays and denials likely contribute to why MA enrollees use fewer of these services than people in traditional Medicare, which has no prior authorization requirements for these services. It’s also likely why people with costly conditions tend to disenroll from Medicare Advantage plans at higher rates than other people.

The data also show that people in Medicare Advantage often forgo care in order to avoid going into medical debt and/or having no money to pay for food and rent. Copays and deductibles can be high in Medicare Advantage plans, particularly for post-acute care. People in traditional Medicare, particularly those with supplemental coverage, experience fewer cost-related problems.

Medicare Advantage plans do not appear to do a better job of keeping enrollees healthy than traditional Medicare, based on the available data. Satisfaction rates with both care and wait times is similar in traditional Medicare and Medicare Advantage.

Here’s more from Just Care:
September 20, 2022
Washington State delays plans to give residents a long-term care benefit
If the US does not already have a long-term care crisis, and there’s a good argument we do, it’s hard to imagine we won’t face a crisis shortly. As the cohort of older Americans grows, so does the need for long-term care, and the cost is likely to be prohibitive for most. While Congress is currently sitting on its hands, Washington State passed a state-based long-term care benefit, but its launch is now delayed until 2023, with coverage not beginning until 2026.

Washington is the first state to pass a law offering residents long-term care coverage, albeit quite limited in scope. The benefit covers up to $36,500 in long-term care costs in an individual’s lifetime. It is designed to pay for aide services as well as home modifications and other needs, or 2o hours a week of home care for one year. It could be a huge help for many, and still not enough help for some.

The Washington long-term care benefit, WA Cares Fund, has been delayed to July 2026. To cover the costs of WA Cares Fund, 3.1 million workers in Washington are expected to pay a small payroll contribution beginning in July 2023, much like they do with Medicare and Social Security. Annual costs will be about $302 for someone earning $52,000 or 0.58 percent of earned income. Costs will be far higher for wealthier individuals. You must pay in for at least three years to qualify for the benefit.

Most people don’t realize that Medicare does not cover long-term care. It covers no more than 100 days in a skilled nursing facility for people who have been hospitalized for at least three days and who need daily skilled nursing or therapy services. It also covers some home health care services–between 20 and 30 or so hours a week–for people who are homebound and need skilled therapy or nursing services on an intermittent basis.

Medicaid does cover long-term care. It is an invaluable benefit. But, in order to get Medicaid, your income and assets need to be extremely low. Thankfully, in many states, if your income and assets are above the eligibility level, your health care expenses need to bring your income and assets down to the eligibility level before Medicaid will kick in.

Can the Washington state long-term care benefit work? It’s hard to know. With more than six in ten people needing long-term care at some time in their lives, it will take a lot of money to cover the cost of the benefit. And, many Washington state residents appear to be worried about paying in and not being able to get back what they invested.

Nearly 500,000 Washington state residents have turned to buying private long-term care insurance as an alternative that exempts them from the requirement of paying into the state fund. Private long-term care insurance has always been a gamble, with premiums able to double out of nowhere and the benefit often more limited than people realize.

Congress needs to step in to avert a long-term care tsunami. The population of people over 85 and the population of people with dementia are expected to double by 2042. The cost of long-term care is only rising. Countless people will die needlessly, in isolation, if nothing is done.

Here’s more from Just Care:
April 25, 2022
Traditional Medicare offers better home care benefits than Medicare Advantage
If you have Medicaid or can afford supplemental coverage to fill gaps in traditional Medicare, here’s another reason to think twice before signing up for a Medicare Advantage plan. Researchers at Brown University’s School of Public Health have found that Medicare Advantage plans do not offer the high quality home health care benefits that traditional Medicare offers. Traditional Medicare home health care services are better, they report in JAMA Network.

People in traditional Medicare, overall, have access to far higher quality providers than people in Medicare Advantage plans. Last year, researchers at Brown University found that traditional Medicare offers higher quality skilled nursing facility benefits than Medicare Advantage plans. Medicare Advantage plans contract with poorer quality providers.

Of course, people in good health need not be too concerned about the quality of care their health insurance offers them. But, all of us can be hit by a car, or slip and fall, or otherwise develop a costly condition at any time. So, it’s important to pick a Medicare plan that will meet your needs in the long-term.

Unfortunately, data about the quality of care in particular Medicare Advantage plans is not available. But, the Brown University researchers found that people with costly health conditions were more likely to leave their Medicare Advantage plans and enroll in traditional Medicare. That’s another sign that Medicare Advantage plans are not meeting people’s needs when they need costly care.

For their home health care study, the researchers analyzed data from 4.4 million people who received home health care. They could not independently assess the quality of the home health agencies serving people in Medicare Advantage plans. Instead, they determined quality based on star ratings, which can be seriously flawed. They found a “significantly” greater likelihood of getting high-quality care in traditional Medicare than in Medicare Advantage. Consequently, people in Medicare Advantage plans may suffer negative health outcomes.

The researchers posit that Medicare Advantage plans save money by contracting with lower quality home health care agencies, just as they save money by contracting with lower quality skilled nursing facilities. Unfortunately, the Centers for Medicare and Medicaid Services does not factor in the quality of home health care agencies in a plan’s network when determining a Medicare Advantage plan’s star rating.

The Kaiser Family Foundation has also looked at the quality of providers in Medicare Advantage plans and found that people in these plans are less likely to be able to use centers of excellence when they have cancer.

Here’s more from Just Care:
November 20, 2019
Medicare coverage of nursing home care is very limited
Planning ahead for a time when you may not be able to care for yourself means recognizing that, unless you qualify for Medicaid, you may need to pay out of pocket for nursing home care. Medicare coverage of nursing home care is very limited.

Unlike Medicaid, Medicare never pays for custodial nursing home care, basic care that does not require treatment from a skilled nurse or therapist. Medicare only covers nursing home care for people needing skilled care who have been hospitalized as an inpatient for at least three days in the 30 days prior to admission in a nursing home. If you meet these criteria, Medicare should cover your care for up to 100 days (the first 20 days in full and the remaining 80 days with coinsurance) if:
1. You are admitted to a Medicare-certified skilled nursing facility; and,
2. You need daily skilled nursing services, seven days a week or physical therapy services at least five or six days a week; and your doctor certifies your need for this care.
Note: Medicare should pay for nursing home care that helps maintain your condition as well as care that improves your condition.

On admission, it is possible that a Medicare-certified nursing home may tell you that it does not believe Medicare will cover your care and ask you to sign a waiver agreeing to pay for the care you will receive. The nursing home may do so to protect itself financially if Medicare denies coverage because Medicare does not think you meet the coverage criteria.

If you sign the waiver, you may be financially liable if Medicare does not cover your care. However, you should make sure that the nursing home still submits the claim to Medicare, along with a letter from your doctor explaining your need for daily skilled services. This is called a “demand bill.” There is a good chance that Medicare may ultimately pay for your care.

If the nursing facility admits you without asking you to sign the waiver, you are not financially liable if Medicare denies coverage. But, if the nursing home asks you to sign the waiver prior to admission and you refuse, the nursing home is not obligated to admit you.

Keep in mind that hospitals sometimes admit people as outpatients on observational status and not as inpatients. Even if you stay overnight for three days and you are admitted as an outpatient, you will not qualify for skilled nursing facility care, regardless of whether you need it. Speak to your doctor about ensuring you are admitted as an inpatient if you are hospitalized.

Click here to learn about your rights in a nursing home. And, don’t be misled by five-star nursing home ratings.

Here’s more from Just Care:
August 14, 2018
Observation care: What you need to know

For the last couple of decades, instead of admitting all Medicare patients who stay overnight as inpatients, hospitals have been providing some patients with “observation” care and treating them as outpatients. Patients are generally unaware of the difference. But, getting observation care leave Medicare patients with huge health care bills without their knowledge.

A new federal law, which takes effect at the end of 2016, will require hospitals to notify patients if they are not admitting them but rather providing them only with observation care. The NOTICE Act or the Notice of Observation Treatment and Implication for Care Eligibility requires that hospitals let patients know within 24 hours that they are receiving observation care, explain the reasons for this care, and advise them of the possible financial consequences.

You should talk to your doctor if you or someone you love is going to the hospital overnight to make sure the doctor ensures you are admitted for inpatient care and, if not, why not; you should also plan ahead for the visit by following these seven simple steps.

Hospital patients who are not admitted as inpatients can end up paying a lot more for their care. Medicare’s hospital benefit, which only kicks in for inpatients, is more generous than Medicare’s medical insurance coverage, which applies to people getting observation care. Among other things, inpatients have their drugs fully covered. Moreover, Medicare patients needing rehabilitation care or skilled nursing care only qualify for coverage if they have been inpatients for at least three days in the thirty days prior to admission.

Observation care is a classification hospitals use for patients they claim are not sick enough to be admitted and not well enough to be sent home. But, hospital incentives are such that they may take a more liberal view of what constitutes observation care than appropriate. For example, they may want to make it seem that their hospital readmission rates are low to improve their quality ratings and payments from Medicare.

There’s compelling evidence that hospitals may be manipulating the observation care classification for their benefit. It’s otherwise hard to explain how the percentage of patients receiving observation care in 2013 is so much greater than in 2006.

Several states, including New York, Connecticut, Maryland, Virginia and Pennsylvania, already have passed laws according similar rights to patients receiving observation care as the NOTICE Act.

For more reading on this topic, see this article in Health Affairs.

January 27, 2016
Are hospitals driving up costs for people with Medicare to improve quality ratings?

In a new Health Affairs post, David Himmelstein and Steffie Woolhandler argue that Medicare’s pay-for-performance system might be doing more harm than good, when it comes to hospital readmissions. Hospital readmission rates are not dropping as much as the data might suggest. Rather, they say that while some hospitals have redesigned their systems to improve patient care pre-discharge so that patients do not need to be readmitted soon after, other hospitals have been gaming the system to make it appear so.

Medicare’s new payment incentive system financially penalizes hospitals with high readmission rates. To meet quality standards imposed by the Centers for Medicare and Medicaid services, some hospitals have been reclassifying patient visits within 30 days after discharge so they do not count as readmissions. They either classify patients as outpatients, on “observational” status, or they admit these patients to the emergency room.

As a result, hospital quality improvement is likely not as significant as the Medicare readmission data would suggest. What’s worse, hospitals that fail to “readmit” patients who have been discharged within 30 days may be penalizing those patients financially. Even if they remain on observational status for several days, they will be ineligible for Medicare skilled nursing or rehab services. (To qualify for Medicare skilled nursing or rehab coverage, patients must be admitted to hospital as inpatients for at least three days in the 30 days prior to getting that care.) And, their out-of-pocket costs could be significantly higher while in hospital.

To support their claims, Himmelstein and Woolhandler reveal that hospital outpatient stays increased 96 percent in the seven years between 2006 and 2013. The rise in outpatient stays represents more than half of the decline in reported hospital readmission rates. There has also been a notable increase in hospital emergency department visits.

Hospital charges are already sky high in most areas of the country. And, competition is not reining them in. Some purchasers are using reference pricing to bring them down. Health economist Uwe Reinhardt makes the case for an all-payer payment system.

September 4, 2015