FEATURED ‘Elephant in the Room’: Medicare Advantage a Huge Factor in CCRC Decision Making Around Nursing Home Services

[rmhaire]

So I'm wrong that they do not have to be in the Hospital for 3 nights before an MA plan will pay? MA observation copay is the same as a night in the hospital with the plans I use. Difference is with MA they could still get skilled nursing paid if they weren't actually admitted.


Yes, it was a family member and 14 other alzheimer's residents that got ran through daily until I put a stop to it. Sorry you had to go through that with your wife, it is a terrible disease. These patients weren't on hospice yet so guess that's why they thought they could do it.

There's no simple answer when discussing UO or SNFs, so no you're not wrong ... It depends

If we're talking about SNFs we're talking about the 3 Midnight Rule. And if we're talking about Under Observation we're talking about the 2 Midnight Rule. And from there, we're talking about OM versus MA.

When someone is in the hospital and they are Under Observation, they are not considered an in-patient. If they have Original Medicare with or without a supplement, Part A will not pay. They would be covered under Part B. So to say that there is no coverage would be incorrect.

It can get even more complicated with an MA plan. With MA there is no part A or B. So how does the hospital get paid?

MA plans are not required to follow Medicare's rules pertaining to UO. This subject is addressed when the company and the hospital hammer out the details of their contract. Each carrier is different.

 

[straightnochaser]

Actually the exact opposite of this is true.

SNFs, HHCs, Nursing Homes and Hospice Providers are strictly regulated by Medicare. Has nothing to do with OM or MA.

There will always a few providers that try to play the system. Just as there will always agents that are just short of being outright crooks.

Maybe you younger agents should actually visit a nursing home or hospice provider. You'd be surprised what you might find.

You'll only get so much from a website or an article. But experience ain't one of them.

The irony

 

[somarco]

There are major changes afoot for Medicare Advantage plans in 2024 and when they are required to cover inpatient services in hospitals for their members. The changes are likely to present challenges for hospitals and how physicians document inpatient care.

In December 2022, CMS proposed a rule that sought "to ensure that Medicare Advantage enrollees receive the same access to medically necessary care they would receive in traditional Medicare." In April 2023, CMS published the final rule, clarifying that MA plans must also follow the two-midnight rule, its case-by-case exception and the inpatient-only list.

Six things to know about the two-midnight rule and how it applies to Medicare Advantage

The 2-midnight rule and Medicare Advantage: 6 things to know

Medicare Advantage plans in 2024 must cover inpatient services in hospitals, presenting challenges for hospitals and physicians. Learn about the two-midnight ru

www.beckerspayer.com

Education and keeping current is a good thing for agents who clients.

Agents with policyholders often skip class . . .

 

[Midlevel]

There are major changes afoot for Medicare Advantage plans in 2024 and when they are required to cover inpatient services in hospitals for their members. The changes are likely to present challenges for hospitals and how physicians document inpatient care.

In December 2022, CMS proposed a rule that sought "to ensure that Medicare Advantage enrollees receive the same access to medically necessary care they would receive in traditional Medicare." In April 2023, CMS published the final rule, clarifying that MA plans must also follow the two-midnight rule, its case-by-case exception and the inpatient-only list.

Six things to know about the two-midnight rule and how it applies to Medicare Advantage

The 2-midnight rule and Medicare Advantage: 6 things to know

Medicare Advantage plans in 2024 must cover inpatient services in hospitals, presenting challenges for hospitals and physicians. Learn about the two-midnight ru

www.beckerspayer.com

Education and keeping current is a good thing for agents who clients.

Agents with policyholders often skip class . . .

Try picking up a 2024 MA brochure and reading where it says no prior hospital stay is required for skilled nursing. They all still say it. Surprised you didn't catch that in your class (google search).

 

[Speechman]

No rumor there. Very accurate. Saw it first hand in the 16years I spent in SNFs. With OM there is and has been so much abuse

 

[Speechman]

StepahnieCJ you are correct

 

[StephanieCJ]

Where does this rumor come from?

The attending has to attest that the patient needs care in an SNF before they can be admitted. Once admitted, the first Medicare recertification cannot occur later than 14 days following admission. Thereafter, the time frame for recertification cannot exceed 30 days.

Not a rumor. What I have actually seen. One SNF actually told a client's husband that they could keep her for 100 days if she would leave her MAPD and go back to OM so he wouldn't be stuck dealing with her dementia at home. I didn't say they all do it, but in my area, it is rampant. Several SNFs here are owned by the same group and part of their admitting paperwork is signing something that they can "assist" in insurance changes in order to facilitate longer care. They assist by going on Medicare.gov and signing the person up for a PDP only.

Providers sign contracts with MCO's, Medicare and other third party payers. Part of the contract states that they agree to accept the fee schedule in the contract as "paid in full".

The only negotiation is, take it or leave it.

That's exactly my point. If the SNFs would work together and "leave it" then the MCOs would be forced to adjust their fee schedules. Plans are required to have a certain number of each type of provider depending on what type of plan (HMO, LPPO, RPPO, etc.). If they can't get a minimum number of SNFs, then they have to make things more attractive. As long as they are able to satisfy the network requirements from CMS, they have no incentive to increase reimbursement.

 

[StephanieCJ]

Actually the exact opposite of this is true.

SNFs, HHCs, Nursing Homes and Hospice Providers are strictly regulated by Medicare. Has nothing to do with OM or MA.

There will always a few providers that try to play the system. Just as there will always agents that are just short of being outright crooks.

Maybe you younger agents should actually visit a nursing home or hospice provider. You'd be surprised what you might find.

You'll only get so much from a website or an article. But experience ain't one of them.

I did not post an article or find anything on the internet. This is my 8+ years of working in the field with almost a 50/50 split of clients between MA and Supp/OM. I have stepped foot in (and smelled) several of the facilities in my region.

 

[StephanieCJ]

Medicare.gov

www.medicare.gov

Search your area. You will likely find abuse of the system more prevalent at the 1 and 2 star facilities (which is about half of the facilities in my area).

 

[somarco]

A skilled nursing facility is ideal for short-term support, while nursing homes offer long-term residential care. The services provided by these facilities are similar and often overlap, but there are a few key differences to understand.

What separates nursing homes and stand-alone skilled nursing facilities, also called rehabs, from each other is the level of medical care provided, the staff on hand, and the duration of the stay.

Skilled Nursing Facility vs. Nursing Home

Skilled nursing facilities are designed for short-term rehabilitative support, while nursing homes also offer long-term care. Both provide high-level medical assistance.

www.aplaceformom.com

Hospitals have enough leverage to move the reimbursement needle . . . sometimes. Normally happens when contracts expire or about to expire. Even then, we are talking single digit percentages.

Smaller providers have no leverage. Nursing home chains, maybe, but again, not much leverage to see noticeable improvements in reimbursement levels.

Even if they do gain reimbursement increases, when they are dealing with an MCO those rascals can put the hammer down for certifying and re-certifying stays.

And FWIW, I rarely use internet searches but I do read a dozen+ industry newsletters daily. These are mostly provider newsletters . . . frontline soldiers who see action daily and have a different perspective than agents or carriers.

I gotta ask . . . are the naysayers talking about SNF's or nursing homes or ECF's ? There is a difference although some on this board use the terms as if they are the same thing . . . but they are not.

SNF's and rehab centers are short term care facilities. ECF's, memory care, etc are for longer stays usually with limited nursing care.

Finally, some things are administered differently now vs even 3 years ago. No matter what someone may have seen, or thought they experienced years ago should no longer apply given CMS rule changes.