Navigating the Challenges of Medicare Advantage: A Critical Concern for Nursing Home Residents and Their Families

Post by: Kimberly Valentine

As experienced elder abuse attorneys, our firm is dedicated to advocating for the rights and well-being of our most vulnerable citizens. Recently, a troubling trend has emerged in the world of nursing home care that warrants public attention and understanding. Medicare Advantage (MA) plans, while seemingly beneficial, are now being reported as having created significant challenges for health care providers including nursing homes and, most importantly, for the residents who rely on these facilities for their care.

The Issue at Hand

Medicare health plans provide Part A (Hospital Insurance) and Part B (Medical Insurance) benefits to people with Medicare. These plans are generally offered by private companies that contract with Medicare. They include Medicare Advantage Plans (Part C) along with others. Medicare Advantage plans promise comprehensive coverage for seniors. However, these plans have been criticized for their lower reimbursement rates compared to traditional Medicare and the heavy administrative burdens they impose. Nursing home operators report facing an uphill battle, dealing with extensive prior authorizations and frequent payment denials, which strain their resources and affect the quality of care provided to residents.

Medicare Advantage Enrollment Form and a red pen


The Reported Financial Strain on Nursing Homes

One of the most pressing issues with Medicare Advantage plans is their stagnant reimbursement rates. According to Chris Chirumbolo, CEO of Ohio-based Carespring Health Care Management, these rates have remained unchanged for long periods, despite rising operational costs, especially since the onset of the COVID-19 pandemic. This financial strain is reported by nursing homes as requiring them to reconsider their payer sources, often turning to Medicaid as an alternative.

In the past, Medicaid was considered an unattractive option due to its underfunding, which left long-term care facilities complaining that they were struggling to cover costs. Medicaid reportedly underfunded the care of a long-term care resident by $30 to $80 per resident per day, depending on various factors such as the state’s reimbursement rate and the facility’s age and amenities. However, the landscape is changing, and more states are recognizing the need to adequately fund long-term care through Medicaid. As a result, the funding gap between Medicare and Medicaid has started to shrink.

Advocacy for Change

As advocates for elder rights, it is crucial to support the push for a “rate floor” for Medicare Advantage plans. Advocacy groups are fighting to ensure these plans provide fair and adequate reimbursement rates to healthcare providers. This battle is essential to protect the quality of care for residents and the financial stability of nursing homes. Some larger, multi-site organizations have begun to negotiate better rates or even move away from MA plans entirely, leveraging their size and influence.

Key Points to Consider

  • Reimbursement Rates: Medicare Advantage plans often offer lower rates than traditional Medicare, but what will that mean long term. Elders as they reach the age of needing to decide on traditional Medicare versus Medicare Advantage need to be mindful that behind the scenes nursing homes are denying admission to patients with Medicare Advantage plans due to lower reimbursement rates to them. What good is coverage if elders cannot be admitted to a facility if and when they need one.
  • Administrative Burden: Healthcare providers are reporting extensive prior authorizations and frequent payment denials adding stress and reducing efficiency in care delivery. Again, this calls into question whether selecting Medicare Advantage is really the best option for Medicare benefits.

The Path Forward

Families of nursing home residents must be aware of these financial and operational dynamics. We urge families to stay informed and engaged with their loved ones’ care facilities. Understanding the challenges Medicare Advantage plans are causing can help families make better decisions about what coverage to obtain as well as advocate more effectively for their loved ones’ care.

By raising awareness and supporting advocacy efforts, we can work towards a healthcare system that truly prioritizes the well-being of our elders, ensuring they receive the high-quality care they deserve.

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