After 11 days in a St. Paul, Minnesota, 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鈥檛 well enough to leave.
鈥淭his seems unethical,鈥 said daughter Amy Loomis, who feared what would happen if the Medicare Advantage plan, run by UnitedHealthcare, ended coverage for her mother鈥檚 nursing home care. The facility gave Christopherson a choice: pay several thousand dollars to stay, appeal the company鈥檚 decision, or go home.
Health care providers, nursing home representatives, and advocates for residents say Medicare Advantage plans are increasingly ending members鈥 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 鈥 at a minimum 鈥 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.
鈥淚n traditional Medicare, the medical professionals at the facility decide when someone is safe to go home,鈥 said , an attorney at the Center for Medicare Advocacy, a nonprofit law group that advises beneficiaries. 鈥淚n Medicare Advantage, the plan decides.鈥
, a vice president of the National Association of State Long-Term Care Ombudsman Programs who directs Connecticut鈥檚 office, said, 鈥淧eople 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鈥檙e already trying to recuperate.鈥
The federal government pays Medicare Advantage plans a monthly amount for each enrollee, regardless of how much care that person needs. This raises 鈥渢he potential incentive for insurers to deny access to services and payment in an attempt to increase profits,鈥 according to by the Department of Health and Human Services鈥 inspector general. Investigators found that nursing home coverage was among the 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鈥 coverage. In August, it asked for on how to prevent Advantage plans from limiting 鈥渁ccess to medically necessary care.鈥
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鈥檚 School of Nursing and an expert on nursing home reimbursement and regulation, said nursing homes have an incentive to extend residents鈥 stays. 鈥淟ength of stay and occupancy are the main predictor of profitability, so they want to keep people as long as possible,鈥 she said. Many facilities still have empty beds, a lingering effect of the covid-19 pandemic.
When to leave a nursing home 鈥渋s a complicated decision because you have two groups that have reverse incentives,鈥 she said. 鈥淧eople are probably better off at home,鈥 she said, if they are healthy enough and have family members or other sources of support and secure housing. 鈥淭he resident ought to have some say about it.鈥
Jill Sumner, a vice president for the American Health Care Association, which represents nursing homes, said her group has 鈥渟ignificant concerns鈥 about large Advantage plans cutting off coverage. 鈥淭he health plan can determine how long someone is in a nursing home typically without laying eyes on the person,鈥 she said.
The problem has become 鈥渕ore widespread and more frequent,鈥 said Dr. Rajeev Kumar, vice president of the Society for Post-Acute and Long-Term Care Medicine, which represents long-term care practitioners. 鈥淚t鈥檚 not just one plan,鈥 he said. 鈥淚t鈥檚 pretty much all of them.鈥
As Medicare Advantage enrollment has spiked in recent years, Kumar said, disagreements between insurers and nursing home medical teams have increased. In addition, he said, insurers have hired companies, such as Tennessee-based naviHealth, that use data about other patients to help predict how much care an individual needs in a skilled nursing facility based on her health condition. Those calculations can conflict with what medical teams recommend, he said.
UnitedHealthcare, which is the largest provider of Medicare Advantage plans, bought naviHealth in 2020.
Sumner said nursing homes are feeling the impact. 鈥淪ince the advent of these companies, we鈥檝e seen shorter lengths of stays,鈥 she said.
In a recent news release, naviHealth said its 鈥減redictive technology鈥 helps patients 鈥渆njoy more days at home, and health care providers and health plans can significantly reduce costs.鈥
UnitedHealthcare spokesperson Heather Soule would not explain why the company limited coverage for the members mentioned in this article. But, in a statement, she said such decisions are based on Medicare鈥檚 criteria for medically necessary care and involve a review of members鈥 medical records and clinical conditions. If members disagree, she said, they can appeal.
When the patient no longer meets the criteria for coverage in a skilled nursing facility, 鈥渢hat does not mean the member no longer requires care,鈥 Soule said. 鈥淭hat is why our care coordinators proactively engage with members, caregivers, and providers to help guide them through an individualized care plan focused on the member鈥檚 unique needs.鈥
She noted that many Advantage plan members prefer receiving care at home. But some members and their advocates say that option is not always practical or safe.
Patricia Maynard, 80, a retired Connecticut school cafeteria employee, was in a nursing home recovering from a hip replacement in December when her UnitedHealthcare Medicare Advantage plan notified her it was ending coverage. Her doctors disagreed with the decision.
鈥淚f I stayed, I would have to pay,鈥 Maynard said. 鈥淥r I could go home and not worry about a bill.鈥 Without insurance, the average daily cost of a semiprivate room at her nursing home was $415, according to of facility charges. But going home was also impractical: 鈥淚 couldn鈥檛 walk because of the pain,鈥 she said.
Maynard appealed, and the company reversed its decision. But a few days later, she received another notice saying the plan had decided to stop payment, again over the objections of her medical team.
The cycle continued 10 more times, Krupa said.
Maynard鈥檚 repeated appeals are part of the usual Medicare Advantage appeals process, said Beth Lynk, a CMS spokesperson, in a statement.
When a request to the Advantage plan is not successful, members can appeal to an independent 鈥渜uality improvement organization,鈥 or QIO, that handles Medicare complaints, Lynk said. 鈥淚f an enrollee receives a favorable decision from the QIO, the plan is required to continue to pay for the nursing home stay until the plan or facility decides the member or patient no longer needs it,鈥 she explained. Residents who disagree can file another appeal.
CMS could not provide data on how many beneficiaries had their nursing home care cut off by their Advantage plans or on how many succeeded in getting the decision reversed.
To make fighting the denials easier, the Center for Medicare Advocacy to help Medicare Advantage members file a grievance with their plan.
When UnitedHealthcare decided it wouldn鈥檛 pay for an additional five days in the nursing home for Christopherson, she stayed at the facility and appealed. When she returned to her apartment, the facility billed her nearly $2,500 for that period.
After Christopherson made repeated appeals, UnitedHealthcare reversed its decision and paid for her entire stay.
Loomis said her family remains 鈥渕ystified鈥 by her mother鈥檚 ordeal.
鈥淗ow can the insurance company deny coverage recommended by her medical care team?鈥 Loomis asked. 鈥淭hey鈥檙e the experts, and they deal with people like my mother every day.鈥