Three years ago, Meredith Phillips’ mother, Georgia Svolos, fell and broke her kneecap, setting off a downward spiral that landed her in nursing homes on and off for a year. In one facility, she fell and broke her knee again, necessitating more surgery. All of the facilities were noisy and chaotic, and one smelled of feces. So, when Phillips learned recently about moves by the Trump administration to ease regulations and fines on nursing homes, she was alarmed. “I’m horrified and frightened,” says Phillips, who lives in Westbrook.
Next year, seniors with private Medicare Advantage insurance policies whose doctors leave their plan may be able to leave, too, under a new Medicare rule. The Centers for Medicare & Medicaid Services (CMS), which oversee Medicare Advantage programs, will create a special three-month enrollment period in any state where insurers make network changes “considered significant based on the affect or potential to affect, current plan enrollees,” according to an update to Medicare’s Managed Care Manual. The special enrollment period – if granted by CMS – would allow Medicare Advantage members to switch out of their plans and join traditional Medicare or another Medicare Advantage plan whose provider network includes their doctors. The mid-year special enrollment period wasn’t an option in 2013 when more than 32,000 UnitedHealthcare Medicare Advantage members in Connecticut were affected by the company’s decision to drop thousands of doctors from its network of providers. The Fairfield County Medical Association sued the company to stop the terminations but was ultimately unsuccessful.
Starting Wednesday, a new state law requires Connecticut hospitals to tell all patients when they are being kept in the hospital for observation instead of being admitted and to warn them about the financial consequences. Anyone who goes to the hospital can be placed on observation status, so that doctors can determine what’s wrong, and decide whether the patient is sick enough to be admitted or well enough to go home. Observation patients may receive diagnostic tests, medications, some treatment, and other outpatient services. Depending on their insurance, they can be charged a share of the cost. “They are in a regular hospital bed in a hospital room, getting a hospital level of care, and they have no way of knowing they were not admitted,” said Rep. Susan Johnson, a sponsor of the legislation and co-chair of the General Assembly’s Public Health Committee.
UnitedHealthcare’s decision last fall to drop thousands of doctors from its Medicare Advantage plans in Connecticut and across the country has spurred Medicare officials to improve protections for seniors who lose their doctors. The new measures were announced late Monday along with a slight increase in next year’s payment rates to Medicare Advantage insurers who provide policies as an alternative to the traditional government-run Medicare program. Nearly 16 million older Americans have enrolled in a Medicare Advantage plan, including more than 147,000 in Connecticut, which requires members to get treatment only from a network of health care providers. They cannot change plans during the year if their doctor leaves their network. The new rules require insurers to provide at least 90 days advance notice of significant changes in their provider networks and allow members to switch plans under certain circumstances.
A lawsuit filed by fourteen seniors, including seven from Connecticut, seeking Medicare nursing home coverage was dismissed Monday by a federal court judge in Hartford. The seniors were among more than a million Medicare beneficiaries who enter the hospital for observation every year. Because they did not spend at least three consecutive hospital days as admitted patients, Medicare will not pay for their nursing home care. In their lawsuit, they argued that there is little difference between observation and admitted patients, except when it comes to paying tens of thousands of dollars in nursing home bills. They asked the judge to eliminate the ‘observation care’ designation or at least set up an expedited appeals process so that their observation status would be reviewed. They also wanted the judge to order Medicare officials to require hospitals to tell patients if they are receiving ‘observation care’ and have not been admitted.
Roberta Baxter, a 78-year-old retired instructional assistant for the Killingly school system, dislocated her kneecap after a fall in her bathroom last September. Following treatment at a local hospital, she spent seven weeks at a nursing home for rehab so that she could walk again. While she was recovering, she and her husband Bill received the first of several bills from the nursing home. That’s when the couple learned Medicare wouldn’t cover the $16,000 cost because Roberta didn’t spend at least three consecutive days in the hospital as admitted patient, or inpatient, as Medicare requires. Instead, the four days she spent in the hospital was for “observation care.”
“I thought it was surely a mistake,” she said. “Nobody ever said I wasn’t admitted.”
Last Friday (5-3), lawyers representing 14 seniors, including 7 from Connecticut, appeared in U.S. District Court in Hartford to ask a judge to eliminate the observation care designation because it deprives Medicare beneficiaries of the full hospital coverage they’re entitled to under Medicare, including coverage for follow-up nursing home care. The judge did not rule on the case. The Centers for Medicare & Medicaid Services (CMS), which runs the Medicare program, pays for doctor visits, hospitalization, nursing home care, prescription drugs and other benefits for nearly 50 million older or disabled Americans, including about 586,000 in Connecticut.
The Westside Care Center in Manchester is ranked among the best nursing homes in Connecticut, receiving a ‘five-star’ rating for overall quality under a federal rating system. At the same time, Westside has the state’s highest percentage of residents who receive antipsychotic drugs, even though they do not have a psychosis or related condition that regulators say warrants their use. Federal data shows 68 percent of Westside long-stay residents were receiving the drugs – more than double the state’s average of 26 percent, which already ranks in the top-third of states nationally. A C-HIT review of federal nursing home data from December found that Westside is not alone: High antipsychotic use, considered dangerous and unnecessary in many cases, does not impact quality ratings of nursing homes, and is often unknown to consumers selecting a home. In three-dozen Connecticut homes, at least a third of long-stay residents are on antipsychotics – yet nearly half of those homes have excellent overall ratings, of 4 to 5 stars.