Please join us for a special edition of the Nursing Home Network this Friday, January 20 at 1 p.m. ET. We are soliciting feedback related to the recently-proposed rules governing Medicare Advantage and Special Needs Plans practices and policies in 2024 and beyond. The proposals include efforts to change current plan behaviors related to denying care that would be approved in traditional Medicare (FFS). LeadingAge will submit comments to CMS on these rules and we want to hear from you on how things work/don’t work today. 

Email Nicole Fallon if you are unable to join the call but would like to contribute feedback.

Below are some questions to consider in advance of the call: 

1. Bring an example of a situation where a Medicare Advantage organization denied care that would have been covered until Medicare FFS. What were the circumstances (e.g., diagnosis, co-morbidities, days of service requested)? How do you determine how many days of service are needed? Are there a minimum number of days for all circumstances? What was the reason for denial? Did you appeal? If so, how long did the appeal take? What happened to the enrollee/beneficiary during the appeal? If appeal approved, how many additional days were granted? How many prior authorizations or reauthorizations do you typically have to request for an MA enrollee?
2. How often would you say prior authorizations or reauthorizations are denied? What are the main reasons for denial? How many days of service are typically approved for initial authorizations? For reauthorizations?
3. How often are beneficiaries discharged on a Friday with an order for home health but HH services are unable to be established over the weekend?
4. What are the key items you consider in determining how many days of service the beneficiary needs? How often is this reassessed?
5. When care is denied, what situations are plans not considering in their determination that are important?
6. What would make prior authorization submissions easier for providers?
7. When a company like NaviHealth uses a data algorithm to determine amount of care a plan will authorize, how does it match up to your assessment of need? What do you think is missing from this tool in determining appropriate care?
8. If plans would be required to cover a “course of treatment” once approved by a plan via a prior authorization, how would you define “course of treatment” as it applies to SNF care? What elements should be included (e.g., care plan? Something else) to make sure the days and services you’ve identified for the individual are covered?
9. How often do you have a SNF admission without a prior 3-day inpatient hospitals stay when someone is on MA? – 3-day waiver

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