A proposed rule issued by CMS would change Medicare Advantage plans’ ability to limit the way covered benefits are provided when traditional Medicare covers different provider types or care settings.
Specifically, MA plans cannot deny authorization based on internal clinical criteria that are stricter than Medicare coverage rules. The rule is designed to ensure MA members are not wrongly denied coverage for post-acute care in certain care settings, such as skilled nursing facilities.
“If an MA patient is being discharged from an acute care hospital and the attending physician orders post-acute care at a SNF because the patient requires skilled nursing care on a daily basis in an institutional setting, the MA organization cannot deny coverage for the SNF care and redirect the patient to home health care services unless the patient does not meet the coverage criteria required for SNF care,” the rule states.1
These changes would supersede current policy under a June 2000 final rule that allows MA plans to choose how covered services are provided “when a health care service can be Medicare-covered and delivered in more than one way, or by more than one type of practitioner.”
Patients are increasingly directed to home health care services, rather than settings like skilled nursing facilities, MedPAC data show. In March 2020, 16.6% of inpatient hospital discharges were referred to SNFs, dropping to 14.9 percent by October 2020. Meanwhile, 20.9% received home health care services.2,3
With the new rule, CMS aims to address concerns about early termination of services in post-acute care settings, it said. It also seeks comments on:
- How MA organizations preauthorize treatment in discrete increments and how the agency’s proposals might address or limit this;
- Whether enrollees should have additional time to file appeals to the Quality Improvement Organization about terminations of services;
- Whether enrollees should receive information from MA plans on the reason for termination of services as part of a termination notice;
- Whether an enrollee whose coverage is reinstated based on a Quality Improvement Organization decision should have more than two days from the date of a new termination of services notice before coverage can be terminated again, accounting for medical necessity determinations made by the QIO.
The agency further requested stakeholder comment on the burden the rule would create for MA plans, saying it cannot estimate the impact, as many plans may already be operating in alignment with the proposals. Comments on the rule are due by Feb. 13.
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References
- Medicare Program: Contract Year 2024 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, etc. Federal Register. Dec. 14, 2022. https://www.federalregister.gov/public-inspection/2022-26956/medicare-program-contract-year-2024-policy-and-technical-changes-to-the-medicare-advantage-program.
- Mullaney, T. CMS Seeks to Stop Diversion of Some Medicare Advantage Patients from SNFs to Home Health. Skilled Nursing News. Dec. 18, 2022. https://skillednursingnews.com/2022/12/cms-seeks-to-stop-diversion-of-some-medicare-advantage-patients-from-snfs-to-home-health/
- Post-acute care Skilled nursing facilities Home health services Inpatient rehabilitation facilities Long-term care hospitals. MedPAC. July 2022. https://www.medpac.gov/wp-content/uploads/2022/07/July2022_MedPAC_DataBook_Sec8_SEC.pdf
