​A flurry of television commercials, often featuring celebrities, brought Medicare Advantage (MA) to the attention of millions of Americans with promises of great and innovative benefits. However, after enrollments surged, reality didn’t necessarily live up to the hype, and MA plans have come under scrutiny by the government and various stakeholder organizations, including the American Health Care Association and the National Center for Assisted Living (AHCA/NCAL). These efforts have resulted in some positive changes. However, more needs to be done. In the meantime, understanding how to work with these plans and advocate for your residents can make a difference.

Martin AllenThere is a role for MA plans, but there is a need for oversight moving forward. “Providers are seeing lower reimbursements with MA plans, as well as numerous restrictions on authorized stays,” said Martin Allen, CPA, AHCA/NCAL senior vice president of reimbursement policy. For instance, lengths of stay may be 10-15 days under MA, compared to 30 days with fee for service. “Restrictions on lengths of stay equate to more demands on staff and less time to resolve the issues that brought [residents] to us,” he noted. “In the last two years, there has been more regulatory activity directed at MA plans, which is good news for our residents and providers. But more work is needed to ensure that MA plans follow the new rules, and we are staying on top of that.”

Challenges for Providers

AHCA/NCAL has identified several MA-related challenges for providers (ahcancal.org/Reimbursement/Medicare/Pages/Medicare-Advantage.aspx):

  • MA plans often pay outside of federally required timelines and create administrative complexities, which jeopardize care.
  • Research raises new questions about the cost effectiveness of Medicare Advantage.
  • Providers and beneficiaries have inadequate avenues and options for communicating with federal officials on challenges associated with MA plan coverage and operations.
  • Stronger provisions are needed to ensure plans comply with federal requirements for important functions related to ensuring access to needed services (e.g., prior authorizations, timely processing of grievances and appeals). Legislation was recently introduced to address prior-authorization challenges.
  • The federal government rarely significantly engages in plan corrective action.

In November 2023, a post-acute care (PAC) stakeholder group that included AHCA/NCAL sent a letter to Meena Seshamani, deputy administrator and director of the Center for Medicare at Centers for Medicare & Medicaid Services. (CMS), identifying several areas of additional guidance required regarding the final 2024 MA Policy and Technical Rule (CMS-4201). These included:

  • MA plans should be required to follow Medicare regulations, including CMS transmittals, CMS provider manuals, the Jimmo v. Sebelius settlement policy, and PAC assessments, in addition to other items already identified in the final rule.
  • CMS should provide examples and clarification of the limited circumstances in which a plan can override a physician’s medical-necessity determination.
  • CMS should identify the specific actions MA plans must take and circumstances when they employ internal coverage criteria, including how that information is to be publicly disclosed and the evidence and tools the plan used to develop the criteria. AHCA/NCAL suggests this should align with the rules the Medicare administrative contractors follow in these situations.
  • CMS should clarify the specific elements that must be contained in denial notices, such as person-specific details for why a service is denied or terminated, what information is lacking, any internal criteria used to make the decision, the specific regulatory requirement that isn’t met, the health professional who reviewed the request, and specific denial codes.
  • CMS should prohibit use of algorithms or artificial intelligence (AI) in coverage denials and limit other uses of these tools until a systematic review of their use can be completed.
  • CMS should clarify the application of the term “course of treatment” in PAC settings, such as a prior authorization for a course of treatment that follows the beneficiary across care settings, covers an entire PAC stay based upon an in-person PAC assessment of the beneficiary, and may require services from more than one PAC provider. This includes changes in condition that extend the need for services.

These recommendations are aimed at addressing a variety of concerns about MA. For instance, Allen said, “network adequacy is a common theme with behavioral/mental health services. There is a concern that MA plans may not have enough providers to offer these services.” He pointed to the success of telemedicine to provide services during the pandemic and said, “We believe that we can continue to meet patient needs by having access to mental health practitioners through telehealth.”

Impact on Person-Centered Care

“MA plans put Medicare benefits into their own models in terms of authorizing and paying for services, and this has an impact on person-centered care. We are advocating for post-acute beneficiaries on this,” said Allen. He noted that there is a proposed rule to require the same kind of appeals process for MA denials as there is in traditional Medicare.

He explained, “We are optimistic about this. The proposed rule says that if MA plans are out of compliance, they have to fix it. This will put some teeth into oversight. It will take some time to implement this, but CMS seems committed to holding plans accountable.”

Beneficiaries often aren’t aware of these kinds of issues and the limitations of MA plans. The commercials bombarding the airwaves have often glorified MA plans. At the same time, when beneficiaries talk to health care agents, they may not be aware that some may financially benefit from recommending specific plans. Allen said, “CMS has recognized that these ads are misleading and put a limit on compensation for agents. This will take out some of the bad actors, and limit ads with misleading statements.”

This will help providers who patients go to for assistance in understanding Medicare coverage. “Our residents may come down to a skilled nursing facility business office and ask questions about MA plans in general or their plan specifically,” said Allen. “We can refer them to materials on the CMS website and cite reliable information.”

Prior Authorization Challenges

Nisha HammelGetting the necessary prior authorization to provide care under MA can be challenging for providers. Nisha Hammel, vice president of reimbursement policy and population health at AHCA/NCAL, said, “When physicians say a patient needs skilled rehab, MA plans often approve the medically necessary care only in a lower-cost setting, such as the home. And even when approved, providers have to submit supporting documentation every few days as to why the stay needs to be extended.” This, she said, creates an administrative and paperwork burden for the facility. It also can be upsetting to the patient and/or family, who are attempting to make plans for caregiving and may feel the person is being sent home before they are ready.

The good news is that in 2024, MA plans have new rules to abide by to prevent these issues. Effective January 1, plans can only use prior authorization to determine diagnosis for medical necessity and, when prior authorization is given, plans can’t deny coverage later due to lack of medical necessity. This is designed to put constraints on inappropriate plan practices, Hammel said.

“MA plans are supposed to cover what traditional Medicare covers, so CMS says that they have to follow traditional Medicare guidelines,” said Hammel. As a result, when prior authorization is provided, it has to be done for an active course of treatment and stay in place until that treatment is completed.

Patients Need Information

When it comes to patients and MA, Hammel stressed the importance of “communication, communication, communication. It’s better to overcommunicate than not communicate enough.” When patients are admitted to a facility, it is useful to help them understand what their MA means in terms of the care and coverage they are eligible for. “It is important to help them understand that you will make assessments and recommendations and advocate for them but that you are not the final decision-maker,” she said. “We want to ensure they have successful outcomes. We can help by making sure that beneficiaries are aware of their rights and how to advocate for themselves. Then we can support them with their appeals as necessary.”

Hammel stressed that even in the best of circumstances, dealing with care and coverage issues can be difficult for families, who may need support.

Allen agreed, explaining, “Social services and admissions staff are great at these kinds of interactions and should have access to all the information and data they need. This can be emotional and time consuming for patients and families, and we need to provide as much support as possible.”

A Practitioner’s View

Karl Steinberg, MD, CMD, a California-based geriatrician and medical director, explained, “Typically, MA plans conduct concurrent reviews, so lengths of stay are shorter.” These patients generally have case managers monitoring their progress and deciding when they’ve met their goals and are no longer eligible for skilled care.

Many MA plans, Steinberg offered, contract with groups that use predictive analytics that look at someone’s parameters to determine length of stay and impose penalties if a patient stays any longer. “This is a disservice to patients, who are individuals and not widgets, and it goes against the concept of person-centered care that is essential to high-quality long term care.”

He added that there is an appeals process; and, he said, “some groups will go along with the provider’s recommendations, for example, that a patient needs more skilled days.” Other times, he noted, “we aren’t comfortable with the decision, but we can’t unilaterally grant a person extra days.” However, regardless of the outcome, the appeals process can be stressful and time consuming for patients and providers alike.

MA plans are basically managed care plans, which are designed to be more efficient and less wasteful. However, Steinberg suggested that when finance people step in and are making decisions with AI software, it can result in negative outcomes for patients and providers. “More physician groups are getting out of MA because they’re losing money, while plans’ use of AI and predictive analytics is counter to their mission of providing compassionate health care services,” Steinberg said.

Action on the Agenda

AHCA/NCAL continues to follow developments related to MA and is working to advocate for patients and providers. Steinberg suggested a few steps providers can take. “Understand the coverage and be willing to have an open dialogue about reasonable lengths of stay. Know who the decision-makers are at plans and in medical groups, including who you can contact if there are disagreements,” he said. “Recommend your patients utilize the appeals process judiciously. Otherwise, groups won’t make a habit of sending patients your way.

“Some MA plans or at-risk entities have per diem rates for skilled care that are even lower than what Medicaid pays for custodial care. Carefully look at the numbers and keep your eyes wide open.”

It will be important to stay on top of efforts to hold MA plans accountable. Hammel said, “It is a little early to get a sense of how things will play out, but we’ll be monitoring things; and we urge members to share their experiences working with MA plans with us.”