Medicare Advantage Plans May Shorten Stays to Less Time than Original Medicare Covers

nursing home careA common question among many of our readers is whether Medicare covers long-term care. Medicare does not cover any type of long-term care, whether in nursing homes, assisted living communities, or your own home. Medicare does, however, cover most short-term stays for rehabilitation after a hospitalization, and in some situations, Medicare Advantage plans are cutting these stays short.

What DOES Original Medicare Cover and for How Long?

Medicare Part A, which covers inpatient hospital services, also covers short-term stays for rehabilitation/therapy care (physical therapy, occupational therapy, and speech therapy) in a Medicare-certified skilled nursing facility (SNF, usually pronounced as “sniff”), also simply called a nursing home, when certain requirements are met. Hospitals frequently send patients to SNFs to receive therapy services and/or specialized skilled nursing care services after a hospital stay. These are some of the rules surrounding what Medicare will and will not cover when a hospital sends a patient to a SNF:

  • Qualifying hospital stay is needed: Care in a SNF is covered only if you had a qualifying hospital stay, meaning that you were formally admitted as an inpatient to the hospital for at least three consecutive days, which must cover three midnights. Being admitted to the hospital does not include any days that you are under observation status, which don’t count even if you stayed in the hospital overnight. Read more in my many articles on Observation Status.
  • Find out what day you were admitted: The beginning of your benefit period is the day you are admitted to a hospital as an inpatient or become a patient in a SNF and ends when you have been out of those places for 60 days in a row. You might have more than one benefit period in a year.
  • You must generally be admitted to a skilled nursing facility within 30 days of leaving the hospital for the same illness or a condition related to it.
  • Your doctor must certify that you need daily skilled care from, or under the supervision of, skilled nursing or therapy staff.
  • The portion of the costs that you pay depends on the duration of your eligible stay in a skilled nursing facility. You’ll have the following copayments for each benefit period:
    • $0 for days 1 to 20;
    • $194.50 a day in 2022 for days 21 to 100;
    • All costs days 101 and beyond.

What’s the Difference Between Original Medicare and Medicare Advantage Plans?

If you have Original Medicare, the government pays for Medicare benefits when you get them. Most people who have Original Medicare also purchase a private Medicare Supplement insurance plan (also called Medigap coverage), which covers some or all of the co-pays and deductibles that are not covered by Original Medicare.

Half of the nearly 65 million people with Medicare at some point opt out of Original Medicare and enroll in a Medicare Advantage Plan, also called Medicare Part C coverage. Medicare Advantage Plans are offered by private health insurance companies. If you enroll in a Medicare Advantage plan, the plan will provide all of your hospital coverage and medical coverage, and the government will pay a fixed dollar amount to the Medicare Advantage plan each year for each person enrolled in the plan. Many people confuse Medicare Advantage plans with Medicare Supplement plans, but, as you can see, these are two completely different types of plans.

How Does Medicare Advantage Affect Short-Term Coverage in a Nursing Home?

In all types of Medicare Advantage Plans, you’re always covered for emergency and urgent care. Many Medicare Advantage Plans also offer extra benefits such as dental care, eyeglasses, or wellness programs.

Medicare Advantage plans must cover — at a minimum — the same benefits as Original Medicare, including up to 100 days of short-term rehabilitation/therapy after a qualifying hospital visit. But these private Medicare Advantage plans have some leeway when deciding how much short-term rehabilitation care a patient needs, and this often causes problems.

According to a recent article in Fortune Magazine, health care providers, nursing home representatives, and advocates for residents say Medicare Advantage plans are increasingly ending members’ coverage for short-term rehabilitation services before patients are healthy enough to go home. In many cases, people are going to the nursing home for short-term rehab and then very quickly getting a termination of coverage notice and told they can appeal, which adds to their stress when they’re trying to recuperate.

“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.”

Why Is This Happening?

As mentioned above, 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 the Department of Health and Human Services’ inspector general. Here are more details about what is happening:

  • Investigators found that short-term rehabilitation coverage was among the most frequently denied services by Medicare Advantage plans and often would have been covered under Original Medicare;
  • The limits on short-term rehabilitation coverage come after several decades of efforts by insurers to reduce hospitalizations in an effort to help drive down costs and reduce the risk of infections;
  • The problem has become “more widespread and more frequent,” said Dr. Rajeev Kumar, vice president of the Society for Post-Acute and Long-Term Care Medicine. “It’s not just one plan,” he said. “It’s pretty much all of them.”
  • As Medicare Advantage enrollment has spiked in recent years because of low (or zero) premiums and co-pays and aggressive advertising, disagreements between insurers and rehab teams have increased.

Jill Sumner, a vice president for the American Health Care Association, which represents nursing homes, said her group has “significant concerns” about large Medicare Advantage plans cutting off coverage. “The health plan can determine how long someone is in a nursing home [for short-term rehabilitation] typically without laying eyes on the person,” she said.

Worsening the situation, in a recent news release, naviHealth said its “predictive technology,” which is being used by Medicare Advantage plans to help determine when to cut off a patient’s stay, helps patients “enjoy more days at home, and health care providers and health plans can significantly reduce costs.”

The Centers for Medicare and Medicaid Services (CMS) could not provide data on how many Medicare Advantage enrollees had their short-term rehabilitation care cut off by their Medicare Advantage plans or on how many succeeded in getting the decision reversed when they appealed. However, CMS has said that it will start cracking down on unwarranted denials of members’ coverage. To make fighting the denials easier, the Center for Medicare Advocacy created a form to help Medicare Advantage members file a grievance with their plan. Hopefully these issues will be resolved for Medicare Advantage members who need longer stays for short-term rehabilitation.

Review Your Medicare Health Plan Every Year, and if You Have Medicare Advantage, Consider Switching Back to Original Medicare

Medicare Open Enrollment begins this week, spanning from October 15-December 7, 2022. As explained in this article, nursing home rehabilitation coverage is frequently cut short by Medicare Advantage plans. Another major problem we see with Medicare Advantage plans is that each plan is “in network” with only a few nursing homes, meaning that if you need short-term rehabilitation, your Medicare Advantage plan will force you to go to one of the few nursing homes that they are “in network” with, thus severely limiting your ability to choose the best rehabilitation center for your needs.

The good news is that the Medicare Open Enrollment Period each year offers a chance to make changes, including switching back from a Medicare Advantage to Original Medicare. Yes, it will probably require a significant increase in premium, but you must also understand that you will be getting significantly better coverage.

Farr Law Firm is excited to continue our affiliation with Retirement & Medicare Together to serve the Medicare needs of our clients. We are working with Retirement & Medicare Together because of their knowledge, experience, and dedication to client service. Now is a perfect time to review your plan and start thinking about making any necessary changes. Click here to schedule your no-cost Medicare review today!

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About Evan H Farr, CELA, CAP

Evan H. Farr is a 4-time Best-Selling author in the field of Elder Law and Estate Planning. In addition to being one of approximately 500 Certified Elder Law Attorneys in the Country, Evan is one of approximately 100 members of the Council of Advanced Practitioners of the National Academy of Elder Law Attorneys and is a Charter Member of the Academy of Special Needs Planners.

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