​The evolving health care landscape continues to present new opportunities for skilled nursing facilities (SNFs) and Medicare Advantage (MA) beneficiaries to access necessary care. The powerful changes included in the Medicare Advantage Contract Year 2024 Final Rule, which took effect at the beginning of 2024, are reshaping how care is accessed and managed. As we navigate through the current year, these changes remain crucial for SNFs to leverage.

Significant Changes Impacting SNFs

The most impactful updates drastically affect prior authorization and medical necessity determination. The MA Final Rule specifies that prior authorization will only be used to confirm a diagnosis or other medical conditions. Once a diagnosis is confirmed, beneficiaries no longer need prior authorization from their MA insurer. For instance, a beneficiary admitted from the hospital with a confirmed diagnosis bypasses the need for prior authorization. Furthermore, once prior authorization is granted, it remains valid as long as medically necessary.

Medical necessity determination has also shifted. Now, it is based on a beneficiary’s prior medical history and the recommendation of the treating physician. Previously, the MA insurer’s medical director determined medical necessity. This change allows the treating physician to make the decision, improving beneficiaries' access to comprehensive care.

Additionally, MA plans are required to align coverage more closely with traditional Medicare, adhering to its benefit guidelines, Local Coverage Determinations, and National Coverage Determinations. When coverage criteria are undefined, MA insurers may use internal guidelines, which must be publicly available and summarized with evidence considered during development.

New network requirements for Medicare Advantage organizations (MAOs) mandate MA insurers to reimburse facilities at the PDPM rate when working out-of-network. Interestingly, providers working in-network are often paid less than their out-of-network counterparts.

The Growing Impact of Medicare Advantage Plans

Medicare Advantage is not just a passing trend; its influence is here to stay and grow. In 2023, more than 50 percent of all Medicare-eligible beneficiaries were enrolled in an MA plan. This trend is expected to continue, with enrollment rates rising in many regions across the United States. As MA plans become more dominant, SNFs must adapt to ensure they can effectively manage these relationships and maintain census levels.

Rate erosion should be a strong consideration for when forecasting future budgets and roadmaps. Providers may use their quality mix to determine financial success, but need to look closely at what payers make up that quality mix. Most MA plans pay less than the Traditional Medicare Default rate, with some plans paying as low as Medicaid rates. Many providers are still budgeting at a fee-for-service Medicare rate, when the patients they’re admitting are MA beneficiaries, with rates that could be up to 50 percent less than what was budgeted.

Given this substantial growth, it is vital for SNFs to understand and navigate the complexities of MA plans. Providers who fail to do so risk falling behind as the MA landscape evolves.

Taking Action

This progress empowers SNFs to reclaim control from MA insurers. However, challenges persist as some insurers resist complying with new requirements that may impact their financial interests. Often, information is not communicated effectively; MA case managers might be unaware of or misinterpret the MA Final Rule’s requirements.

Given that Medicare Advantage remains prevalent, with over 50 percent of Medicare beneficiaries enrolled in an MA plan, SNFs must strategically manage these insurers. Here’s how:

1. Understand the MA Final Rule: Ensure familiarity with the rule’s specifics. Your case manager and admissions director should have a copy and be well-versed in its details.
2. Initiate Conversations: Proactively engage with MA case managers. Clearly communicate your understanding of the new requirements and set your expectations.
3. Address Non-Compliance: If insurers push back, inform them you will contact your CMS regional office. Highlight how their actions limit beneficiary access to care. Use key phrases such as:

• “The MAO is limiting beneficiary’s access to care.”
• “The MAO is not providing the same coverage as traditional Medicare.”
• “The MAO is not following the current MA Final Rule guidelines.”

CMS Regional Offices Contact Information

• Atlanta: (404) 562-7150 (AL, FL, GA, KY, MS, NC, SC, TN)
• Boston: (617) 565-1188 (CT, ME, MA, NH, RI, VT)
• Chicago: (312) 886-6432 (IL, IN, MI, MN, OH, WI)
• Dallas: (214) 767-6427 (AR, LA, NM, OK, TX)
• Denver: (303) 844-2111 (CO, MT, ND, SD, UT, WY)
• Kansas City: (816) 426-5233 (IA, KS, MO, NE)
• New York: (212) 616-2200 (NJ, NY, PR, VI)
• Philadelphia: (215) 861-4140 (DE, MD, PA, VA, DC, WV)
• San Francisco: (415) 744-3501 (AS, AZ, CA, GU, HI, NV, MP)
• Seattle: (206) 615-2306 (AK, ID, WA, OR)

Looking Ahead

The future holds more changes. The CY 2025 MA Final Rule, released in April 2024, details new requirements for the MA appeal process. Effective January 1, 2025, MA beneficiaries will have access to a five-level system similar to traditional Medicare appeals. This change would involve independent reviewers from CMS-affiliated Quality Improvement Organizations (QIO) handling appeals of MA plan service terminations. Further, the CY 2025 MA Final Rule fully eliminates current regulations that require MA beneficiaries to forfeit their right to appeal a termination of services to the QIO when discharged from a SNF.

Maureen McCarthy is the CEO and Founder of Celtic Consulting, a long term care advisory firm that delivers operational, clinical, and financial support to health care providers. McCarthy can be reached at mmccarthy@celticconsulting.org or 860-321-7413.