It’s a safe bet he’ll focus on hot-button issues like our nation’s economy, the war in Ukraine and escalating gun violence. It would be nice if he also revisits a promise that helped get him elected: immigration reform.

Why should that last topic matter to long-term care providers? Two reasons.

The first is patently obvious. There is a critical shortage of caregivers in long-term care. An analysis by the American Health Care Association found that more than 300,000 jobs have been lost in this sector since the arrival of COVID-19. And it’s not like the shelves were well stocked before then.

The second is that targeted immigration reform could greatly help alleviate this ongoing – and worsening – challenge.

Under different circumstances, changes that open pathways for foreign-born caregivers might seem to be a no-brainer. Sadly, we live in times where seemingly every issue is mere fodder for a partisan divide. Small wonder so many of our elected officials appear more interested in bashing opponents than fixing problems.

It seems that for every advocate of eased immigration, there is a dug in opponent. Each side is armed with plenty of talking points.

But what’s not open for debate is whether the nation’s need for caregivers is growing by the day. It is.

According to the Bureau of Labor Statistics, employment in healthcare support jobs is projected to increase by 1.3 million in the coming years. That’s a lot of open positions. 

It’s hardly a stretch to suggest immigrants could greatly help fill that void. In fact, many already do help. By some estimates, more than a quarter of all frontline workers in skilled care are foreign born.

On the day he took office, Biden called for changes that would create a pathway to citizenship for undocumented workers. There has been scant movement since. And now that Congress is a house divided, the odds are that much worse.

But while we dither, another nearby nation is taking action. Canada welcomed more than 400,000 new permanent residents last year. In fact, one in 10 participants in its labor force is now an immigrant. And that figure is projected to triple in less than 15 years.

So what lessons can we take here regarding immigration reform? Canada is showing that where there’s a will, there’s a way. As for the United States? Well, we’re clearly demonstrating that the opposite also happens to be true.

John O’Connor is editorial director for McKnight’s.

Opinions expressed in McKnight’s Long-Term Care News columns are not necessarily those of McKnight’s.

The $1.7 trillion omnibus spending bill, released Monday, includes a concession on Medicare pay cuts to doctors, extends pandemic-era telehealth flexibilities, averts a hospice cap cut and Pay-As-You-Go sequestration reductions, and considers support for the senior care workforce. The legislation also increases funding for Alzheimer’s research. 

The bill must be finalized, approved by both houses of Congress and signed by President Biden, but legislators are hoping to pass the legislation by Friday, sources told medical news outlet STAT.

Under the bill’s current terms, physicians will not receive a 4.5% Medicare pay cut in 2023 as previously proposed. Instead, the cut will be limited to 2% next year and rise to 3.5% in 2024, STAT reported.

Telehealth extension, workforce support

Meanwhile, there will be a two-year extension of pandemic-era telehealth flexibilities that will open this benefit to more recipients. Employers would be able to offer telehealth services pre-deductible to people who have high deductible health plans and a health savings account, according to senior living industry advocate Argentum.

Provisions also include $5 billion in disaster relief funding related to Hurricane Ian, language that supports older adults’ ability to use retirement savings to pay for long-term services and supports, and improvements to the healthcare workforce, reported McKnight’s Senior Living.

Federal agencies would be urged to support the expansion of the skilled nursing workforce and provide home- and community-based services to older adults and people with disabilities using education and training grant programs, and apprenticeship programs.

“This significant investment in workforce with a focus on senior care within the Department of Health and Human Services and Department of Labor will have a profound impact on our industry within the next year and decades to come,” said Maggie Elehwany, senior VP-public affairs for senior care advocate Argentum.

Two other senior living policy items did not make it into the bill: immigration reform and the expansion of access to assisted living for veterans.

Home care pluses and minuses

Home care providers called the legislation a “mixed bag.” While home health was pleased with the prevention of so-called PAYGO cuts for 2023 and 2024, it did not win a delay of Medicare cuts related to the Patient-Driven Groupings Model that are scheduled to take effect Jan. 1.

And the hospice industry received some concessions, according to the National Hospice and Palliative Care Organization, a hospice advocacy organization. The legislation does not reduce the aggregate cap for hospice payments by 20% as previously proposed. Yet it contains provisions that will slow the cap’s growth, which the NHPCO said will serve to further restrict access to hospice care for patients with Alzheimer’s disease and other dementias.

The legislation also would designate $1 million to assess the development of quality standards for bereavement and grief care, and would expand the use of marriage and family therapists and mental health counselors as part of hospice interdisciplinary teams.

Access to drugs

Beyond long-term care, the legislation will aim to help Americans transition to commercial coverage of drugs that have received emergency approval during the pandemic. These include COVID-19 vaccines and treatments and other drugs provided for free from government stockpiles, which are gradually depleting. 

Visit McKnight’s Senior Living for additional context on the legislation’s impact.

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Although many skilled nursing providers let out a sigh of relief after the Centers for Medicare & Medicaid Services announced a 2.7% net pay increase for SNFs in 2023 on Friday, others were still expressing plenty of concern. 

CMS issued the SNF Prospective Payment System final rule for fiscal 2023 on Friday. Providers’ pay boost includes a 3.9% SNF market basket increase plus a 1.5 percentage point forecast error adjustment, as well as a 0.3% lower productivity adjustment. 

However, it also includes a 2.3% (or $780 million) decrease as a result of a Patient Driven Payment Model’s parity adjustment to account for unintentional overpayments. The recalibration of PDPM’s parity adjustment factor of 4.6% includes a two-year phase in period in a win for providers — decreasing SNF spending by 2.3% in fiscal 2023 and 2.3% in fiscal 2024. 

Combined, the two adjustments will result in an estimated aggregate increase of about $904 million in Medicare Part A payments to SNFs for fiscal 2023. 

“Providers should be happy that CMS has chosen to spread the parity adjustment out over two years and that CMS made a slight (1.1%) increase to the market basket update,” said Brian Ellsworth, vice president of public policy and payment transformation at Health Dimension Group. 

“But, overall it is very concerning to have such a small net rate increase during a time period when providers are experiencing significant occupancy pressures, a workforce crisis and double digit wage increases for nurses in many markets across the country,” he told McKnight’s Long-Term Care News on Friday. “Medicare plays such a vital role in skilled nursing facility finances.” 

Grateful that CMS listened

In April 2021, CMS first announced that it intended to recalibrate PDPM pay rates. It said in April 2021 that aggregate spending under the new model was unintentionally 5.3%, or $1.7 billion, higher than intended.

In late July 2021, however, the agency held off on adjusting PDPM payment rates for fiscal 2022. Then, in mid-April this year, it proposed a 4.6% pay reduction when it issued the 2023 SNF PPS proposed rule. An uproar ensued, with providers and some lawmakers ultimately calling on CMS to phase in the cuts over three years to ease the financial pain of the clawback provision.

Sabra Health Care REIT President and CEO Rick Matros, who called CMS’ original pay proposal “heartless,” said the final rule is “very good news” for providers.

“The increase before the reduction was bigger than expected,” Matros told McKnight’s on Friday. “I believe they did listen and I thank CMS for that.” 

The American Health Care Association on Friday said the market basket increase and two-year phase-in of the PDPM parity adjustment were “essential” for providers when accounting for the ongoing workforce and economic challenges they’re facing. 

“Thousands of providers, lawmakers, and stakeholders shared how a swift cut to Medicare would be detrimental to our nursing home residents and staff, and we are grateful that CMS listened and made the necessary changes,” AHCA President and CEO Mark Parkinson said in a statement.

Doesn’t erase ‘financial neglect’

Others, however, were not as conciliatory. LeadingAge leaders doubled down on their disappointment that CMS chose to include the parity adjustment in the final rule. 

“We warned CMS that this is not the time to cut payments,” LeadingAge President and CEO Katie Smith Sloan said in a statement Friday. “Spreading the impact of the adjustment over two years (2.3% in FY 2023 and 2.3% in FY 2024) is helpful, but the end result adds to the chronic financial neglect of our nations’ nursing homes — in a time of real crisis.”

She pointed out that care access, inflation-induced increases in operating costs, staffing shortages and “insufficient support” from policy makers are major issues for providers and now they have to have payment reductions to that list. 

“Any further cuts bring us to a question of whether skilled nursing care will truly be sustainable in many communities,” added Deb Paauw, executive director of quality and data integration at South Dakota-based health system Avera Health. “South Dakota has had four nursing homes announce this year that they are closing, and it’s highly likely there will be more doing the same.”

With the prospect of new strains of the COVID-19 virus looming, researchers are making a case for states to impose vaccination booster shot mandates on nursing home employees.

Mandating healthcare workers to become vaccinated was successful in 2021, and that produced no corresponding worsening of staff shortages, pointed out academic researchers writing in JAMA Health Forum on Friday. 

Barely more than half of nursing home workers currently have received any kind of booster shot, they said, drawing parallels to last summer, when fewer than 60% had received any vaccination shots at all. The number of vaccinated nursing home workers is now just below 90%.

States mandating the worker vaccinations that did not allow the option of more frequent testing instead were much more successful, investigators found.

“These results lend support to the recently upheld federal mandate and should inform ongoing discussion about whether to mandate boosters of additional doses as we head toward fall and new COVID waves,” said Brian McGarry, PhD, assistant professor in the Division of Geriatrics and Aging at the University of Rochester, and the study’s lead author.

“We were surprised by the lack of an effect on the staff shortage rate,” he added in comments to McKnight’s. “There were obviously concerns that the mandates could have had catastrophic effects on staffing levels, but we generally find reported staff shortages were stable, or even a little lower, following the mandate announcement.

“Generally, I think our results suggest that when push comes to shove, staff typically elect to get vaccinated rather than lose their job,” McGarry said.

Some states are already wrestling with the idea of mandating boosters.

New York, for example, first moved to mandate them but tempered that goal over concerns of potential staff losses. Massachusetts, on the other hand, adopted a booster mandate and currently enjoys one of the highest rates of boosted staff.

Friday’s release showed that researchers studied 38 states for the five-month period ending Nov. 14, 2021. Twelve of the states had a vaccine mandate for nursing home employees, four of them with no test-out option.

Ten weeks or more after a mandate’s announcement, states with no test-out choice saw conversion rates jump 6.9 percentage points. Those with a test-out option rose 3.1 points.

“State-level COVID vaccine mandates were an effective policy mechanism for improving vaccination rates among staff, particularly in more conservative counties where baseline vaccination rates were lower,” explained researcher Betsy White, PhD, APRN, an assistant professor in Brown University’s Department of Health Services, Policy & Practice.

She called vaccines “the biggest tools in the toolbox” for protecting nursing home staff and residents against COVID-19. She, McGarry and other research team members have produced many studies of COVID nursing home data during the pandemic. Nursing homes early on were identified as the single most likely setting for COVID-19 infections and deaths. 

“Our findings suggest that if states took ownership of mandating booster doses — which to date only a small number have — that could be an effective policy tool to ensure broader up-to-date vaccination coverage among staff, which protests both staff and residents,” White told McKnight’s. 

She noted that one of the advantages of having states mandate vaccinations instead of individual employers is “they take some of the burden of ‘being the bad guy’ off employers.” They also reduce alternative employment options for unvaccinated staff who may consider leaving to take a job in a different facility,” she added.

She said that health officials need to consider comprehensive requirements for booster doses.

“Our findings give state health departments and policy makers data to inform these decisions around current and future vaccination policies,” White said. “Vaccine-induced immunity wanes over time, particularly in the context of omicron and new variants, and we know that booster doses are needed to remain protected against the virus. Yet barely more than half of staff nationally have received a first booster dose, let alone a second, putting both themselves and residents at risk.”

The nursing home worker booster rate was 54.5%, according to the latest posting of Centers for Disease Control and Prevention data, which reflected provider-submitted data.

Nursing facility staff vaccination rates increased nationally by 25 percentage points, from 63% to 88%, between August 2021 and March 2022. The U.S. Supreme Court upheld CMS’s federal mandate that healthcare workers become vaccinated in January during that time span.

In April, regulators first sought a net $320 million funding takeback from providers, causing stakeholders to deluge the agency with thousands of comments. Operators complained that removing so much funding during the costly pandemic era, and at a time of staffing shortages, would crush many providers.

“After considering the stakeholder feedback received in the FY 2022 SNF PPS rulemaking cycle and on the FY 2023 SNF PPS proposed rule, to better account for the effects of the COVID-19 public health emergency (PHE) on SNF spending, CMS is finalizing the adjustment factor of 4.6% to the SNF payment rates,” the agency wrote in releasing the highly anticipated new rule late Friday afternoon.

In another major victory for providers fearing the worst, CMS also said it “recognizes that the ongoing COVID-19 PHE provides a basis for taking a more cautious approach to mitigate the potential negative impacts on the nursing home industry, such as facility closures or disproportionate impacts on rural and smaller facilities.”

The result will be a 2.3% Medicare Part A cutback ($780 million) to fiscal 2023 payment rates, and a 2.3% reduction in fiscal 2024. Providers had lobbied for a three-year phase-in period but undoubtedly will be relieved all will not be taken in one fell swoop, as originally proposed by officials.

The proposed rule also included a Request for Information (RFI) seeking input on establishing minimum staffing requirements for long-term care facilities. President Biden made history in announcing proposed sweeping nursing home reforms, including a first-ever federal staffing minimum in his first State of the Union Address earlier this year. 

“We are continuing our work to focus on staffing and value, making sure that Medicare nursing home residents can receive high-quality care based on the needs of the whole person, rather than focusing on the volume of certain services provided to them,” said CMS Administrator Chiquita Brooks-LaSure in a statement announcing the rule.

In April 2021, CMS first announced that it intended to recalibrate PDPM pay rates. The new Medicare payment system went into effect Oct. 1, 2019. It was the biggest change to the nursing home reimbursement system in at least a generation and was supposed to be budget neutral. 

After its debut, however, providers and regulators alike quickly suspected, that federal payments were more generous than the system’s budget-neutral stipulation called for. But five months into PDPM’s implementation, the full force of the pandemic hit, throwing the U.S. healthcare system into a state of uncertainty it had never before encountered. Any plans to readjust PDPM payments were indefinitely postponed.

Regulators announced in April 2021 that aggregate spending under the new model was unintentionally 5.3%, or $1.7 billion, higher than what it would have been under the old Resource Utilization Groups model. The agency solicited comments for how to correct the situation, including possible takebacks for the unintended high payouts.

In late July 2021, however, CMS held off on adjusting PDPM payment rates for fiscal 2022, saying it needed to get a better picture of COVID-19’s full impact on SNFs. 

Then, in mid-April this year, CMS called for a 4.6% pay reduction when it issued its 2023 SNF PPS proposed rule. An uproar ensued, with providers and some lawmakers ultimately calling on CMS to phase in the cuts over three years to ease the financial pain of the clawback provision.

American Health Care Association President and CEO Mark Parkinson applauded CMS’s decision to increase the market basket and provide a two-year phase-in of the PDPM parity adjustment.

“These are essential for long-term and post-acute care providers during this unprecedented workforce shortage and economic crisis. Thousands of providers, lawmakers, and stakeholders shared how a swift cut to Medicare would be detrimental to our nursing home residents and staff, and we are grateful that CMS listened and made the necessary changes,” Parkinson said in a statement. “We greatly appreciate an overall increase to the Medicare program this coming fiscal year to help stabilize the profession and ensure our vulnerable residents have access to necessary, quality care.”

SNF VPB updates

CMS also finalized a proposal to suppress the SNF 30-day, all-cause readmission measure as part of the peformance scoring in the FY 2023 SNF Value-Based Purchasing Program year. This means the performance on this measure will be reported publicly but it will not affect payment.

“CMS is finalizing this proposal because circumstances caused by the COVID-19 PHE have significantly affected the measure and the ability to make fair, national comparisons of SNFs’ performance scores. As part of the scoring policy for FY 2023, CMS will assign a performance score of zero to all participating SNFs, irrespective of how they perform using the previously finalized scoring methodology, to mitigate the effect that PHE-impacted measure results would otherwise have on SNF performance scores and incentive payment multipliers,” the ageny said.

CMS will also reduce the otherwise applicable federal per diem rate for each SNF by 2% and award 60% of that withhold, resulting in a 1.2% payback to those providers. The agency said any SNFs that does not meet the finalized case minimum for FY 2023 will be excluded from the program for the fiscal year.

Among other provisions in the new rule, CMS has decided to “mitigate instability” in SNF PPS payments due to significant wage index decreases that may affect providers in any given year. The agency is finalizing a permanent 5% cap on annual wage index decreases to smooth year-to-year changes in providers’ wage index payments.

A fact sheet on the new rule can be found on the CMS website.

This is a developing story. Please check back for additional updates.

The Centers for Medicare & Medicaid Services has officially delayed action on a three-year-old proposal to reduce some duplicative and “unnecessary” requirements for nursing homes another year, with no clear indication yet of how regulators will proceed when time runs out.

The 2019 proposal would have eliminated some care and reporting requirements for providers — and deliver an estimated cost savings of $616 million sector wide. But it fell by the wayside with COVID and a change in administration and was never finalized.

Earlier this month, CMS officials filed a notice in the Federal Register that the agency had received a one-year extension of its time to act on the burden-reduction rule. The agency could still ax it entirely.

When it was first published, the proposal promised to reform “long-term care requirements that the Centers for Medicare & Medicaid Services has identified as unnecessary, obsolete, or excessively burdensome.” Had it been enacted by now, it would have scaled back several compliance and infection control requirements outlined in Phase 3 of the updated federal Requirements of Participation. Instead, providers must continue to operate under those rules, including new guidance issued in late June.

The red tape-reduction rule came on the heels of a Trump executive order calling on the Department of Health and Human Services to propose several reforms to the Medicare program, largely seen as an effort to reduce paperwork and repetitive processes. The agency asked providers for their insights on possible elimination of Medicare regulations that require “more stringent supervision than existing state of scope of practice laws, or that limit health professionals.”

The rule would have directed more resources to “improving resident care,” the agency said when it was proposed.

Among more than a dozen requirements it would soften or eliminate are the issuance of notices to state ombudsman in all discharge cases; a hasty timeframe for posting daily nurse staffing data; the need for Pro re Nata, or PRN, prescription renewals to only be given following an evaluation by physician or prescribing practitioner; “prescriptive requirements” for QAPI programs; a minimum part-time infection preventionist requirement; and much of a facility’s compliance and ethics program, including the requirement for a compliance officer. 

Many of those Trump-era proposals are in direct opposition to policies and guidelines that have been adopted by CMS under the Biden administration. In fact, several of the requirements that would have been softened by Trump were hardened in the latest Phase 3 guidance.

Taking an additional year to consider the proposed rule doesn’t necessarily mean CMS is planning to abandon the entire burden reduction rule, but it could, one observer noted.

LeadingAge approached CMS about its plans earlier this year, after several providers asked about apparent conflicts regarding which rules were in effect. Any rules that have been finalized – including the Rules of Requirement and its Phase 3 guidance – are the ones providers are beholden too for now, said Jodi Eyigor, director of nursing home quality and policy for LeadingAge.

“They say they are reviewing the provisions of that proposed rule … they’re reviewing the comments they received way back in 2019,” Eyigor told LeadingAge members on a conference call Monday. “We’re not really sure at this point what might happen.”

CMS could implement some of the proposed items; finalize a rule canceling the proposals; or re-open comments. Whatever the choice, the agency now has until July 18, 2023, to act.

The Centers for Medicare & Medicaid Services is in the process of deciding what COVID-19 regulatory waivers will remain permanent or be retired following the end of the public health emergency.

“We are very focused on trying to give everyone as much time in terms of making sure people understand our approach. We’ve already started making some of the changes permanent, such as particularly around mental health for Medicare beneficiaries,” CMS Administrator Chiquita Brooks-LaSure said during a national stakeholder call Tuesday. 

“We continue to evaluate which authorities we have flexibility on and ones that will be ready for the next PHE,” she added. 

The Department of Health and Human Services on Friday extended the public health emergency for another 90 days through Oct. 6, 2022. With the extension, COVID-19 regulatory waivers, such as exceptions to the three-day stay rule and telehealth flexibilities, will be around at least through early October.

A handful of waivers, including one related to temporary nurse aide training, were retired in early May and June. 

“We are absolutely committed to giving full notice, 60 days, for planning and preparation [before] the PHE does close,” said Jonathan Blum, CMS’ principal deputy administrator and COO.

He added that the agency is committed to four areas of focus to help support states and providers once the PHE ending arrives. Those include: maintaining health insurance coverage; providing coverage and reimbursement for testing, vaccines and treatments; issuing new provider regulations and guidance to ensure patient and healthcare workforce safety; and keeping the healthcare system open and accessible through federal and state waivers. 

“[That means] for us to go through a very careful process and very deliberate process to decide what to keep, what to sunset and which waivers could get turned on down the road if certain conditions get met,” Blum said. 

“But we want to make sure that whatever we do we’re doing it in a carefully planned, coordinated way throughout the whole agency and to make sure that we are communicating well, giving ample notice — 60 days minimum — for whatever happens once the PHE comes to a close,” he added.

The Centers for Medicare & Medicaid Services appears to be weighing changes to its nursing home room capacity standards, based on recommendations included in updated guidance released Wednesday. 

The issue was among several key topics addressed in a memo issued Wednesday for nursing home surveyors that updates guidance related to Phase 2 and Phase 3 of the Requirements of Participation. 

The updates had been due since 2019, but were delayed by the agency for additional review prior to the pandemic. Many of the items now being addressed have been informed by nursing homes’ COVID-19 experiences and lessons learned, CMS said.

Infection control and prevention requirements; staffing expectations; dementia care; appropriate diagnoses and medication use; and details on how to better care for residents with mental health and substance abuse disorders were all included in the guidance. All told, the new details bring the requirements to an astounding 847 pages, and providers will continue to parse the details in coming days and weeks.

The updated guidance will go into effect on Oct. 24, 2022, giving “ample time for surveyors and facilities to be trained on this new information,” CMS said. 

The extended deadline was welcomed by the American Health Care Association/National Center for Assisted Living. The association plans to “continue to advocate for resources to help providers make meaningful changes that benefit the safety and wellbeing of our residents,” David Gifford, chief medical officer for AHCA/NCAL, said in a statement to McKnight’s Long-Term Care News on Wednesday.

Resident rooms 

The memo includes recommendations related to resident room capacity, though there are no updated regulations at this time.

“CMS is highlighting the benefits of reducing the number of residents in each room given the lessons learned during the COVID-19 pandemic for preventing infections and the importance of residents’ rights to privacy and homelike environment,” the agency said in a fact sheet.

Currently, CMS allows up to four residents in one room that allows for a minimum of 80 square feet per resident. Bedrooms in newly constructed or renovated facilities must accommodate no more than two residents, according to 2016 CMS guidance.

In response to President Joe Biden’s nursing home reform proposals, the agency plans to align its resident room requirements more inline with the 2016 guidance, CMS wrote. It’s also urging providers to consider making changes to their physical environment to allow for a maximum of double occupancy in each room, and explore more ways to add more single occupancy rooms for residents.

“This also builds on the lessons learned through the COVID19 pandemic, where having more residents in a room can make it more challenging to prevent the transmission of infectious diseases,” the agency wrote.

Staffing 

CMS added new requirements for surveyors to incorporate the use of Payroll Based Journal staffing data for more thorough investigations into provider compliance with staffing requirements. The update comes just months after PBL reporting expanded and as the agency works to establish new minimum staffing requirements for nursing homes.

“This will help better identify potential noncompliance with CMS’s nurse staffing requirements, such as lack of a registered nurse for eight hours each day, or lack of licensed nursing for 24 hours a day,” the agency said in a statement. “This guidance will help to uncover instances of insufficient staffing and yield higher quality care.” 

Katie Smith Sloan, president and CEO of LeadingAge, criticized the agency for “continuing the additional pile-on of regulations [that] will strain already-stretched providers.” 

“We all know that staffing goes hand-in-hand with quality care, and our mission-driven members are working valiantly to stay compliant,” Sloan said in a statement Wednesday. “But we continue to urge the administration to back its words of commitment to ensuring older adults’ access to care with meaningful action and funding.”

Congressional lawmakers are being urged to address weaknesses in Medicare Advantage plans in response to a federal watchdog report that found that the MA organizations have often improperly denied or delayed care to seniors. 

Seniors “may not be aware that they may face greater barriers to accessing certain types of healthcare services in Medicare Advantage than in original Medicare,” said Erin Bliss, assistant inspector general for evaluation and inspections at the Office of Inspector General, said Tuesday. 

Bliss was a witness at a hearing held by the House Committee on Energy & Commerce subcommittee for oversight and investigations, first reported by Kaiser Health Network.

The hearing specifically focused on the oversight of MA plans and also included statements by Leslie Gordon, acting director on the Government Accountability Office’s healthcare team, and James E. Mathews, Ph.D., executive director of the Medicare Payment Advisory Commission. 

An April report by the OIG accused MAOs of sometimes delaying or denying Medicare Advantage beneficiaries’ access to services, even though the requests met Medicare coverage rules.

Post-acute facilities were among the healthcare services often involved in denials that met Medicare coverage rules. The findings spurred an immediate call for change from stakeholders and providers who have struggled with the potential cost of admitting some residents due to the issue in recent years.

“Medicare Advantage beneficiaries in the last year of life are generally in poor health and often require high cost, specialized care,” Gordon said during the hearing Tuesday. “High rates of disenrollment from Medicare Advantage to join traditional Medicare may indicate issues with the quality of care, such as potential limitations accessing specialized care.” 

Gordon added GAO has also found that MA beneficiaries in the last year of life disenrolled to join traditional Medicare at more than twice the rate of other Medicare beneficiaries. 

Lawmakers on Tuesday agreed with the concerns and called for improvements. Seniors should not be “required to jump through numerous hoops” to gain access to healthcare, said subcommittee chair Rep. Diana DeGette (D-CO). 

LeadingAge is advocating for a provider rights’ addition to MA programs that would better enable nursing homes and other aging services organizations to deliver services and be fairly reimbursed for them.

“We know nearly half of Medicare beneficiaries are now enrolled in Medicare Advantage and post-acute providers need to see some changes in MA policies to ensure that they can serve these beneficiaries well,” Ruth Katz, the organization’s senior vice president of public policy and advocacy, said during a call with members Wednesday afternoon.

“The MA program is popular and gets more and more popular both with policymakers and with consumers because of the lower beneficiary out-of-pocket costs…but these are concerns and they have to be addressed,” she added. “We are pushing the administration and Congress to keep this issue on their radar and in their sights.”