The Phoenix

Nursing home surprise: Advantage plans may shorten stays to less time than is needed

- By Susan Jaffe

After 11 days in a St. Paul, Minn., skilled nursing facility recuperati­ng from a fall, Paula Christophe­rson, 97, was told by her insurer that she should return home. But instead of being relieved, Christophe­rson and her daughter were worried because her medical team said she wasn’t well enough to leave.

“This seems unethical,” said daughter Amy Loomis, who feared what would happen if the Medicare Advantage plan, run by UnitedHeal­thcare, ended coverage for her mother’s nursing home care.

The facility gave Christophe­rson a choice: pay several thousand dollars to stay, appeal the company’s decision or go home.

Health care providers, nursing home representa­tives and advocates for residents say Medicare Advantage plans are increasing­ly ending members’ coverage for nursing home and rehabilita­tion services before patients are healthy enough to go home.

Half of the nearly 65 million people with Medicare are enrolled in the private health plans called Medicare Advantage, an alternativ­e to the traditiona­l government program. The plans must cover — at a minimum — the same benefits as traditiona­l Medicare, including up to 100 days of skilled nursing home care every year.

But the private plans have leeway when deciding how much nursing home care a patient needs.

“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.”

Mairead Painter, a vice president of the National Associatio­n of State LongTerm Care Ombudsman Programs who directs Connecticu­t’s office, said, “People are going to the nursing home, and then very quickly getting a denial, and then told to appeal, which adds to their stress when they’re already trying to recuperate.”

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 an April analysis by the Department of Health and Human Services’ inspector general. Investigat­ors found that nursing home coverage was among the most frequently denied services by the private plans and often would have been covered under traditiona­l Medicare.

The federal Centers for Medicare & Medicaid Services recently signaled its interest in cracking down on unwarrante­d denials of members’ coverage. In August, it asked for public feedback on how to prevent Advantage plans from limiting “access to medically necessary care.”

The limits on nursing home coverage come after several decades of efforts by insurers to reduce hospitaliz­ations, initiative­s designed to help drive down costs and reduce the risk of infections.

Charlene Harrington, a professor emerita at the University of California-San Francisco’s School of Nursing and an expert on nursing home reimbursem­ent and regulation, said nursing homes have an incentive to extend residents’ stays.

“Length of stay and occupancy are the main predictor of profitabil­ity, so they want to keep people as long as possible,” she said.

Many facilities still have empty beds, a lingering effect of the COVID-19 pandemic.

When to leave a nursing home “is a complicate­d decision because you have two groups that have reverse incentives,” she said. “People are probably better off at home,” she said, if they are healthy enough and have family members or other sources of support and secure housing. “The resident ought to have some say about it.”

Jill Sumner, a vice president for the American Health Care Associatio­n, which represents nursing homes, said her group has “significan­t concerns” about large Advantage plans cutting off coverage.

“The health plan can determine how long someone is in a nursing home typically without laying eyes on the person,” she said.

The problem has become “more widespread and

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