After 11 days in a skilled nursing facility in St. Paul, Minnesota, recovering from a fall, Paula Christopherson, 97, was told by her insurance company that she should return home.
But instead of being relieved, Christopherson and her daughter were worried because her medical team said she was not well enough to die.
“This seems unethical,” said daughter Amy Loomis, who fears what will happen if the Medicare Advantage plan, run by UnitedHealthcare, terminates coverage for her nursing home care. her mother. The facility gives Christopherson a choice: pay a few thousand dollars to stay, appeal the company’s decision, or go home.
Health care providers, nursing home representatives, and resident advocates say Medicare Advantage plans are increasingly ending members’ coverage of nursing home services aging and rehabilitation before the patient is well enough to go home.
Half of the nearly 65 million people with Medicare are enrolled in a private health plan called Medicare Advantage, an alternative to the traditional government plan. Plans must cover – at a minimum – the same benefits as traditional Medicare, including up to 100 days of skilled nursing home care per year.
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But private plans have delays when it comes to deciding how much nursing home care a patient needs.
“In traditional Medicare, on-site health professionals decide when it is safe to go home,” said Eric Krupa, an attorney at the Medicare Policy Advocacy Center, a nonprofit law group that advises people with disabilities. Beneficiaries. “In Medicare Advantage, the plan decides.”
“People will go to nursing homes, and then very quickly,” said Mairead Painter, vice president of the National Association for State Long-Term Care Ombudsman Programs, who directs the Connecticut office. denied, and then asked to appeal, which added to their stress as they tried to recover. “
The federal government pays the Medicare Advantage plan a monthly amount for each enrollee, regardless of the type of care that person needs. This increases the “potential incentive for insurers to deny access to services and payments in order to increase profits,” according to an April analysis by the Department of Health and Human Services inspector general. Investigators found that nursing home coverage was one of the most frequently denied services by private plans and would typically be covered under traditional Medicare.
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The Federal Center for Medicare & Medicaid Services recently signaled its interest in addressing unwarranted denials of coverage by members. In August, it asked for public feedback on how to prevent Advantage plans from restricting “access to medically necessary care.”
The nursing home coverage limits come after decades of efforts by insurers to reduce hospital admissions, initiatives designed to help lower costs and reduce the risk of infection. coincide.
Charlene Harrington, professor emeritus at the University of California-San Francisco School of Nursing and expert in nursing home regulation and reimbursement, said nursing homes have an incentive to extend their stay. resident. “Duration of stay and occupancy are key predictors of profitability, so they want to keep people around for as long as possible,” she said. Many facilities still have empty beds, the consequences of the COVID-19 pandemic are still lingering.
When to leave a nursing home “is a complicated decision because you have two groups with opposite incentives,” she says. “People are probably better off staying at home,” she said, if they are healthy enough and have family members or other sources of support and safe housing. “Residents must have some say about it.”
Jill Sumner, vice president of the American Healthcare Association, which represents nursing homes, said her team has “significant concerns” about Advantage plans cutting out coverage. “The health plan can determine how long someone typically stays in a nursing home without keeping an eye on the person,” she says.
Dr Rajeev Kumar, vice president of the Society for Long-Term and Post-Acute Care Medicine, which represents long-term care practitioners, said the problem had become “more common and more frequent”. . “It’s not just a plan,” he said. “That’s pretty much all of them.”
As the number of people enrolling in Medicare Advantage plans has spiked in recent years, disagreements between insurers and nursing home medical teams have grown, says Kumar. In addition, he said, insurers have hired companies, such as Tennessee-based NaviHealth, to use data on other patients to help predict the level of care an individual needs in the future. a skilled nursing facility based on her medical condition. Those calculations may contradict what medical groups recommend, he said.
UnitedHealthcare, the largest provider of Medicare Advantage plans, acquired NaviHealth in 2020.
Sumner said nursing homes are feeling the impact. “Since these companies were born, the length of stay is shorter,” she said.
In a recent release, NaviHealth said its “predictive technology” helps patients “enjoy more days at home, while health care providers and health plans can reduce substantial cost”.
UnitedHealthcare spokeswoman Heather Soule would not explain why the company limits coverage to the members mentioned in this article. However, in a statement, she said such decisions are based on Medicare criteria for medically necessary care and involve a review of members’ medical records and clinical status. . If members disagree, she said, they can appeal.
When a patient no longer meets the criteria for coverage in a skilled nursing facility, “it doesn’t mean the member no longer needs care,” Soule said. “That is why our care coordinators actively engage with members, carers and providers to help guide them through an individualized care plan that focuses on unique needs of members.”
She notes that many members of the Advantage plan prefer home care. But some members and their supporters say that choice isn’t always practical or safe.
Patricia Maynard, 80, a retired Connecticut school cafeteria worker, was in a nursing home recovering from a hip replacement in December when her UnitedHealthcare Medicare Advantage plan announced that the plan This program will end coverage. Her doctors disagreed with the decision.
“If I stay, I will have to pay,” Maynard said. “Or I can go home and not worry about bills.” Without insurance, the average daily cost of a semi-private room at her nursing home is $415, according to a 2020 state survey of facility fees. But going home is also unrealistic: “I can’t walk because it hurts,” she says.
Maynard appealed and the company reversed its decision. But a few days later, she received another notice saying the plan had decided to stop paying, again in the face of objections from her medical team.
The cycle continues for 10 more times, says Krupa.
Beth Lynk, a spokeswoman for CMS, said Maynard’s repeated appeals are part of the regular Medicare Advantage appeals process.
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When a claim for an Advantage plan is unsuccessful, members can appeal to an independent “quality improvement organization,” or QIO, which handles Medicare claims, Lynk said. “If the enrollee receives a favorable decision from the QIO, the plan is required to continue paying for the nursing home stay until the plan or facility determines the member or patient no longer needs more,” she explained. Residents who disagree can file another appeal.
CMS was unable to provide data on the number of beneficiaries who had their nursing home care cut off in their Advantage plans or on the number of people who succeeded in revoking the decision.
To make it easier to fight denials, the Medicare Policy Advocacy Center created a form to help Medicare Advantage members file a complaint with their plan.
When UnitedHealthcare decided it wouldn’t pay Christopherson’s 5 more nursing home days, she stayed at the facility and appealed. When she returned to her apartment, the facility charged her nearly $2,500 for that period.
After Christopherson repeatedly appealed, UnitedHealthcare reversed its decision and paid for her entire stay.
Loomis said her family remains “mysterious” by her mother’s ordeal.
“How could the insurance company deny coverage offered by her medical care team?” Loomis asked. “They are professionals, and they deal with people like my mother on a daily basis.”
Kaiser Health News is a national health policy news service. This is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
