Medicare Advantage compliance: access, confidentiality, advance directives, post-stabilization care, home SNF return, and quality improvement
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Compiles federal regulatory requirements governing Medicare Advantage organizations' responsibilities for provider access, confidentiality and accuracy of enrollee records, advance directive policies, post-stabilization care financial responsibility, return-to-home skilled nursing facility rights, liability protections, and quality improvement programs; applies to MA organizations, their plans, enrollees, providers, and contracted facilities.
No material clinical or coverage changes in this revision.
Coverage Criteria and Regulatory Requirements
Posthospital extended care and post-stabilization financial responsibility
Rules governing enrollee choice to receive posthospital extended care through their home skilled nursing facility and parity of coverage:
Confidentiality, advance directives, and liability protections
Requirements for handling enrollee records and advance directives:
Quality improvement and access to services
Quality improvement and provider access requirements:
Coding, Definitions, and Payment
| (a) General rule | MA plans must provide coverage of posthospital extended care services to Medicare enrollees through a home skilled nursing facility if the enrollee elects to receive the coverage through the home skilled nursing facility, and if the home skilled nursing facility either has a contract with the MA organization or agrees to accept substantially similar payment under the same terms and conditions that apply to similar skilled nursing facilities that contract with the MA organization. |
| (b)(1) | The skilled nursing facility in which the enrollee resided at the time of admission to the hospital preceding the receipt of posthospital extended care services. |
| (b)(2) | A skilled nursing facility that is providing posthospital extended care services through a continuing care retirement community in which the MA plan enrollee was a resident at the time of admission to the hospital. |
| (b)(3) | The skilled nursing facility in which the spouse of the enrollee is residing at the time of discharge from the hospital. |
| (b)(4) | If an MA organization elects to furnish SNF care in the absence of a prior qualifying hospital stay under § 422.101(c), then that SNF care is also subject to the home skilled nursing facility rules; references to hospitalization or discharge are deemed to refer to wherever the enrollee resides immediately before admission for extended care services. |
Provider Responsibilities and Actions
End of MA financial responsibility for post-stabilization care
The MA organization's financial responsibility for post-stabilization care services it has not preapproved ends when one of the four statutory triggers occurs: (i) a plan physician with privileges at the treating hospital assumes responsibility for the enrollee's care; (ii) a plan physician assumes responsibility through transfer; (iii) an MA organization representative and the treating physician reach an agreement concerning the enrollee's care; or (iv) the enrollee is discharged.
- Trigger (i): plan physician with hospital privileges assumes responsibility
- Trigger (ii): plan physician assumes responsibility through transfer
- Trigger (iii): agreement between MA representative and treating physician
- Trigger (iv): enrollee discharge
Access to services and freedom of choice
MA private fee-for-service plans must demonstrate to CMS that they have a sufficient number and range of providers willing to furnish services, by meeting one or more of these conditions: (i) payment rates not less than original Medicare, (ii) contracts/agreements with a sufficient number and range of providers, or (iii) a combination of payment parity and contracts; enrollees must be permitted to obtain services from any Medicare-authorized entity that agrees to the plan's terms.
- Sufficient access may be shown by payment rates at or above original Medicare for the provider category
- Or by contracts/agreements with a sufficient number and range of providers
- Or a combination of payment parity and sufficient contracts
- Freedom of choice: enrollees may obtain services from any Medicare-authorized entity that agrees to the plan's terms
Key Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.