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.

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.

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 & 17 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.

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.

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.

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?

Agents: Share Your Expertise

Seniors: Ask a Question of Your Own

Agent Locator

Medicare Agents HubA non-government resource website

Medicare Agents Hub
A non-government resource website