How will the recent attention & auditing around Medicare Advantage plans effect nursing home coverage?

Question

Alaina Hunt · Accepted Answer

The recent attention and increased auditing of Medicare Advantage plans is focused on ensuring these plans are following the rules and putting patients’ needs first. One area under scrutiny is how these plans manage care in nursing homes—particularly the use of prior authorizations and decisions around how long someone can stay in a facility.

What this means for nursing home coverage is that we may see improvements. Audits are likely to reduce practices that led to early discharges or delays in care. The goal is to make sure that if someone truly needs skilled nursing care, they can access it without unnecessary barriers.

That said, it’s more important than ever to have an advocate who understands how each Medicare Advantage plan handles post-acute and long-term care. Plans vary, and being on the right one can make a real difference in what care you or your loved one receives.

Gary Church · Answer

Not sure! The future of healthcare is changing with the current Administration and cuts to social programs will have an effect on healthcare and could on Medicare.

Larry Dalton · Answer

If you or a loved one has a Medicare Advantage plan and lives in a nursing home or might need that level of care, you must stay informed about your Insurance carrier’s Advantage plan coverage.

Due to increased audits from CMS and potential financial challenges with some insurance providers, many are rethinking their participation in the Medicare Advantage program or adjusting their plan offerings.  This could mean certain MA plans, particularly those tied to nursing home networks, might change or become unavailable soon. Stay informed of your Advantage plan with your carrier. These companies can drop you by closing out a coverage block, causing you to scramble for future coverage.  As a result, your beneficiaries may need to be carefully reviewed, and your options to ensure your healthcare needs are meet next year.

During Medicare’s Annual Enrollment Period, (October 15 through December 7), take the time to evaluate whether your current MA plan is still the best fit. It may be beneficial to explore switching to another MA plan or back to traditional Medicare, depending on your specific needs for nursing home care, and whether or not you can qualify for a Medicare supplement plan on traditional Medicare. 

Staying proactive and engaged with your healthcare Agent is the key in keeping good coverage for the future.

Terri Reagin · Answer

it won't. Long term care (Nursing homes) are not covered by Medicare at all. Skilled nursing is a benefit but that is not the same service as full nursing home care and is maxed out at 100 days.

Christopher Boyd · Answer

This causes a lot of confusion. Medicare and Medicare Advantage Plans generally do not cover any Long Term Care. As written in the 2025 Medicare and You Handbook. Only Skilled Nursing/Skilled Care, post acute hospital care is covered up to 20 days. From Day 21 to 100, the patient will most likely have a co-pay. Beyond Day 100, the patient pays 100%. For example, my mother had a stroke years ago and spent over 60 days in the hospital. Medicare and her Medicare Supplement covered 100 days of skilled care in a nursing home. After Day 100, she was deemed "Long Term" by Medicare and 100% private pay. Her Long Term Care Nursing Home policy covered her care from the time forward.

Answered by Christopher Boyd on August 3, 2025

Agent Licensed in IN, KY, MI, OH, PA & TN

Answered by Christopher Boyd Medicare Insurance Agent

George Ibanez · Answer

Nursing homes have nothing to dop with Medicare Advantage plans, since Medicare Advantage plans cover only skilled nursing facilities but they do not cover long term nursing homes, so there should be no effect whatsoever.

Answered by George Ibanez on November 18, 2025

Broker Licensed in AR, AL, AZ & 40 other states

Answered by George Ibanez Medicare Insurance Agent

Mark Maliwauki · Answer

The increased scrutiny and auditing of Medicare Advantage (MA) plans, especially through Risk-Adjustment Data Validation (RADV) audits, is likely to impact nursing home coverage in several ways. Specifically, tighter scrutiny and potential cost containment efforts within MA plans could lead to:

Reduced Payments:
MA plans may reduce payments to nursing homes to offset potential overpayments identified during audits or to balance budgets. 

More Denials and Appeals:
As MA plans face pressure to control costs and maintain compliance, they may be more likely to deny or delay coverage for nursing home stays, leading to increased appeals from beneficiaries and providers. 

Pressure on Nursing Home Contracts:
Contract negotiations between MA plans and nursing homes may become more challenging, with nursing homes potentially facing unfavorable terms to ensure continued coverage. 

Shifting of Costs:
To manage their budgets, MA plans may increase premiums or reduce other benefits, potentially shifting the burden of care to beneficiaries.

Potential Impact on Access:
The combination of reduced payments, more denials, and potential cost-shifting could lead to reduced access to quality nursing home care for some beneficiaries, particularly in rural areas or those with complex medical needs.

Wendy Lollar · Answer

Hopefully it will have a positive effect. I’ve always been told by clients that nursing homes take them from their MA Plans and put them on Original Medicare only for the benefit of the nursing home. They are told that original Medicare doesn’t “question” their billing department but MA’s ask questions. This isn’t an area that I’m very knowledgeable in firsthand, but I do talk to my clients about their experiences.

Answered by Wendy Lollar on January 26, 2026

Broker Licensed in LA, AR, FL, MS & TX

Answered by Wendy Lollar Medicare Insurance Agent

Jason Wisniewski · Answer

With Nursing home coverage you shouldn't rely on any type of Medicare plan be it Medicare Advantage, Medicare Supplement or Original Medicare for long term custodial care but if you're talking about short term stays for Rehab you will get up to 100 days covered on any plan. You should either look at Long term care insurance or if youre nelow poverty level you could apply for Medicaid.

The benefit of a Medicare Advantage plan is that they will cover those short term stays without any prior hospital stay whereas Original Medicare or Original Medicare plus Medicae Supplement requires a 3 day prior Inpatient Hospital stay before they cover it.

With Medicare Advantage plans they do require Nursing facilities to submit clinical information before extending stays which sometimes Nursing home staff are lazy to do. If your plan denies an extended stay is 90 percent of the time because the staff at the Nursing home hasnt given them the clinical information to support the request for extended stay. If you have a broker your broker can help you file an appeal and also put pressure on the Nursinh home staff to submit the required clinical information to get your stay extended

I did that for my father in law successfully and have done it for several other clients as well 

More broadly even Original Medicare  as well as Medicare Advantage plans will be cracking down on Nursing homes for submitting too little clinical information and will require them to start providing more detailed diagnosis

Steven Bleicher · Answer

Tough question to answer at this time due to the current administration’s attitude. Once the lawsuits have been adjudicated by the Supreme Court, we all will know a lot better surrounding your excellent question.

Answered by Steven Bleicher on May 26, 2025

Broker Licensed in AZ

Answered by Steven Bleicher Medicare Insurance Agent

Rick Boyd · Answer

Will a true and honest audit cause change? That is a question I don't have a definitive answer for. Change is needed, along with improved accountability, to ensure that seniors with Advantage plans receive the full number of days allowed for recovery. How this is measured needs to be carefully thought through before the implementation of any new rules.

Answered by Rick Boyd on December 1, 2025

Broker Licensed in KY, AZ, CA & OH, TN, TX & UT

Answered by Rick Boyd Medicare Insurance Agent

Armand Smith · Answer

I do not think it will effect coverage. Nursing homes are only covered for 100 days.. I would advise anyone to buy a short term coverage plan that covers LTC for up to a year and also look in to some hybrid ltc plans.

Answered by Armand Smith on February 26, 2026

Broker Licensed in AZ, CA, CO & 8 other states

Answered by Armand Smith Medicare Insurance Agent

Heidi Delaney · Answer

It's important to know that Ling Term Care also known as custodial care is never covered.  The VA and Medicaid and Long Term Care plans are the only ones that cover those services.  Short term admissions at Skilled Nursing Favilities are covered by Medicare.

At this time, it is too soon to know what impact the audits will have on any of this.

Duane Boebel · Answer

The increased scrutiny and auditing of Medicare Advantage plans are likely to lead to tighter nursing home coverage under MA plans. This is because MA plans are increasingly being held accountable for accurately reporting diagnoses and patient information, which directly impacts their payments. As a result, MA plans may reduce provider payments or benefits, or increase premiums, to offset the cost of increased compliance.

Answered by Duane Boebel on May 27, 2025

Broker Licensed in AL, FL, GA & 9 other states

Answered by Duane Boebel Medicare Insurance Agent

Joshua Ruiz · Answer

The recent intensification of audits and scrutiny of Medicare Advantage (MA) plans by the Centers for Medicare & Medicaid Services (CMS) is poised to significantly impact nursing home coverage, particularly concerning prior authorization practices and patient care decisions.

Answered by Joshua Ruiz on May 22, 2025

Broker Licensed in NC, AL, AZ & 22 other states

Answered by Joshua Ruiz Medicare Insurance Agent

Fred Manas · Answer

The increased scrutiny and auditing of Medicare Advantage (MA) plans by the Centers for Medicare & Medicaid Services (CMS) will likely result in tightening payment rates and potentially more restrictions on nursing home coverage. MA plans are under pressure to balance budgets, which may lead to provider payment reductions or benefit cuts, including potentially nursing home stays. 
Here's a more detailed look: 
Payment Reductions:
MA plans are facing increased pressure to control costs due to the fixed monthly payments they receive from the government, regardless of the individual's care needs. To balance budgets, they may reduce payments to providers, including nursing homes.
Increased Restrictions:
MA plans have been known to deny or limit nursing home coverage, particularly for stays exceeding a certain duration, often without the same level of flexibility as traditional Medicare. The increased auditing and focus on compliance could lead to more restrictions and denials of coverage.
Negotiation Difficulties:
Nursing homes may face more challenging negotiations with MA plans during contract renewal periods, as plans seek to reduce payments in response to budget pressures and audit findings.
Impact on Beneficiaries:
Reduced payments and increased restrictions could impact the quality of care in nursing homes, potentially leading to longer wait times, shorter stays, and reduced access to needed services for MA enrollees.
Importance of Appeal Rights:
Beneficiaries and their families should be aware of their appeal rights when facing denials or limitations on nursing home coverage from MA plans.

Andrew Kramer · Answer

There is no nursing home coverage under Medicare, and therefore also under Advantage plans. So there is no effect by auditing because it's simply not covered.

Jack Mayer · Answer

Do not depend on Medicare to pay for your nursing home coverage. Big mistake because first you need to be hospitalized at least 3 days and your physician must approve your stay and will if he/she thinks you will improve. You pay nothing the first 20 days and thereafter 60 more days and your MAPD plan should cover the very expensive daily co payments. After that your on your own. Medicare only covers skilled care not intermediate or custodial care.

Answered by Jack Mayer on March 16, 2026

Agent Licensed in CA & NV

Answered by Jack Mayer Medicare Insurance Agent

Linda Davies · Answer

Both Original Medicare and Medicare Advantage plans must cover up to 100 days of skilled nursing facility (SNF) care during a benefit period.   

To qualify for SNF coverage, beneficiaries generally need to have been admitted to the SNF within 30 days of a 3-day hospital stay.   

Both cover skilled nursing services and therapy services that are ordered by a doctor and medically necessary.   

The SNF must be Medicare-approved.

Lillian Hill · Answer

The research used to answer this question indicates that the new Medicare Advantage audits are designed to protect beneficiaries—not take away nursing home benefits.

Nursing home coverage is NOT being cut

Benefits — like skilled nursing care after a hospital stay — should stay the same.

The audits are about plan's behavior, not care.

Medicare is making sure insurance companies:
- Follow the rules  
- Don’t overcharge  
- Don’t deny care they should approve  

The goal is fairness — not taking anything away.
These changes may actually HELP seniors

By double‑checking the insurance companies to make sure they treat patients fairly, beneficiaries may see...

- Fewer unfair denials  
- Faster approvals  
- Less hassle getting the care needed  
- More consistent rules that match Medicare  

This is especially important for people who need skilled nursing or rehab. 

🎯

James Wareheim · Answer

It is too soon to know.  Nothing has been released by the government.  Keep in mind Medicare doesn't provide great benefits for long term nursing home care.

Amy Jones · Answer

Nursing homes are not covered under Original Medicare and therefore, they are also not covered by Medicare Advantage plans.

Jermaine Williams · Answer

This create more scrutiny on coverage denials and prior authorizations because of increased government regulation

Adriana De la Cruz · Answer

The increased attention on Medicare Advantage plans could mean some changes to nursing home coverage. We might see stricter rules about who qualifies or how long they can stay, as the goal is to ensure people receive the right care.

Dalton Johnson · Answer

I'm not quite sure! In my opinion, this situation has the potential to go both ways—good and bad. On the positive side, I can see individuals who have previously been denied coverage by certain carriers gaining approval after a closer examination or audit of their individual circumstances. On the downside, I’m concerned that some people who genuinely need nursing facilities might be denied coverage based on their current health conditions.

Ultimately, healthcare is constantly changing and evolving. While we hope these changes lead to improvements, they don't always yield the best outcomes. However, I believe that if these changes negatively impact our senior clients, there will be prompt and precise actions taken to address the issues.

How will the recent attention & auditing around Medicare Advantage plans effect nursing home coverage?

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How will the recent attention & auditing around Medicare Advantage plans effect nursing home coverage?

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