CMS is making an attempt to cease redirecting some Medicare Benefit sufferers from SNFs to House Well being

The Centers for Medicare & Medicaid Services (CMS) takes steps to ensure that patients are not unreasonably denied coverage for post-acute care in certain settings — including qualified nursing facilities — by Medicare Advantage organizations (MAOs).

CMS raised the issue as part of a rule proposal issued Dec. 15, stating that MAOs generally cannot apply more restrictive coverage criteria than traditional Medicare coverage, as set by national coverage determinations (NCDs), local coverage determinations (LCDs), and become Medicare laws. This also applies to certain “substantive coverage criteria and benefit conditions” not governed by an NCD or LCD, including transfers to post-acute facilities.

“For example, if an MA patient is discharged from an acute care hospital and the treating physician orders follow-up care at an SNF because the patient requires skilled care on a daily basis at a facility, the MA organization cannot refuse to cover the costs for the SNF care and Referral of the patient to home healthcare services unless the patient does not meet the coverage criteria required for SNF coverage in §§ 409.30-409.36 and proposed §422.101(b) and (c),” the proposed rule reads.

The agency is proposing to repeal the current policy that “if a health service is covered by Medicare and can be provided in more than one manner or by more than one type of physician, an MA plan could choose how the covered services would be provided. “

MA organizations are not restricted in terms of pre-approval and post-claim verification to ensure benefits meet Medicare coverage rules.

CMS also expressed hope that these steps will help resolve complaints of early termination of treatment in post-acute settings by MAOs.

CMS solicited comments on various related topics, including how MAOs pre-authorize treatment in discrete increments; enrollment deadlines for filing appeals regarding termination of service; and how to handle the restoration of services following Quality Improvement Organization (QIO) decisions.

The American Hospital Association (AHA) commended the proposed rule.

“The AHA has historically raised concerns about the adverse impact of certain Medicare Advantage practices and policies, which have the potential to directly harm patients through unnecessary treatment delays or the outright denial of covered services,” said Ashley Thompson, AHA senior vice president of Public Policy Analysis and Development. “CMS’s proposed rule includes helpful provisions to ensure greater consistency between Medicare Advantage and traditional Medicare by restricting overly restrictive policies that can impede access to care and create costs and burdens on healthcare systems.”

The proposed rule comes as admissions for skilled nursing facilities have fallen while admissions for home nursing have risen.

“In March 2020, at the onset of the COVID-19 public health emergency, the proportion of inpatient hospital discharges referred to SNFs decreased to 16.6% and reached 14.9% by October 2020” , according to MedPAC’s July 2022 databook. “In contrast, the proportion of outpatient nursing increased to 20.9%.”

Medicare Advantage insurers and other managed care organizations have incentives to choose lower-cost home health care over a skilled nursing facility because they seek to deliver services in environments consumers prefer and at lower costs. This trend has been made possible by the creation of SNF home models and other programs to provide more advanced home care. However, SNF-at-home is a slowly growing offer and is still in its infancy.