The Centers for Medicare & Medicaid Services (CMS) recently finalized two Medicare Advantage rules, and the results will likely be positive for skilled nursing facility operators in 2024.
In a rule issued Wednesday, CMS finalized proposals that could decrease the number of Medicare Advantage beneficiaries being diverted from SNFs to home health.
That rule, combined with the MA rate increase that CMS finalized on March 31, are good news for SNFs overall, Fred Bentley, managing director with ATI Advisory, told Skilled Nursing News.
“It’s a 3.32% increase, which is okay — and it’s much better than what was in the advanced notice, which was about 1%,” he said. “So, if I’m a SNF, that means that my Medicare Advantage plans are not going to be trying to squeeze me on reimbursement now. But it doesn’t mean they’re going to be generous.”
In December, CMS proposed that MA Organizations (MAOs) can’t apply coverage criteria that is more restrictive than traditional Medicare coverage. The agency cited the example of beneficiaries inappropriately denied SNF coverage in favor of home health.
Previously, a Health and Human Services Office of the Inspector General (OIG) report published in April 2022 found that among prior authorization requests MAOs denied, 13% met Medicare coverage rules and would have been approved for these beneficiaries under traditional Medicare.
“I would imagine next year that [operators] will likely see fewer restrictions and maybe incrementally more Medicare Advantage beneficiaries coming into their building. I don’t think it’s a floodgate,” Bentley said. “Just because if you’re a SNF, Medicare Advantage is one of several different payers. In some markets, it’s a lot, in some, it’s smaller.”
In January, Skilled Nursing News reported that denials jeopardize post-acute recovery for MA patients, who, in some circumstances, would be sent to a nursing home from the hospital, only to have the MA plan call to say the patient can only stay in the facility for three days.
This new rule may mitigate these issues, by requiring plans to streamline prior authorization practices.
“Prior authorization may not be as big of a hurdle for beneficiaries getting care, which could be helpful on the margins,” Bentley said. “If you’re a SNF and you’ve got a patient in and they’ve been approved, the plan, as I understand it, can’t all of a sudden revoke prior authorization.”
Overall, the rule will have “a bit of a chilling effect on Medicare Advantage plans’ efforts to really grind down on SNF utilization,” Bentley said.
In addition to removing coverage barriers, CMS reported that the ruling will also crack down on misleading marketing schemes by MA plans.
“I still think that Medicare Advantage is going to continue to grow,” Bentley said. “But this may trim sales a little bit or slow that growth, just a hair, because plans can’t necessarily be quite as aggressive as they had been.”
CMS wrote that the ruling will help MA and Medicare Part D plans to more effectively focus both on patient-centric care and on improving clinical outcomes.
“With this final rule, CMS is putting in place new safeguards that make it easier for people with Medicare to access the benefits and services they are entitled to, while also strengthening the Medicare Advantage and Part D programs,” CMS Administrator Chiquita Brooks-LaSure said in a press release.