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agdw70 Asked May 2015

Is it legal for a Medicare Advantage plan to be allowed into a nursing home to try and get residents to enroll?

There is a private insurance/ medicare advantage company that is attempting to come into the facility where I am employed and pitch their CRAP to our naive, trusting residents. I have worked in long term care for 20 years and have seen residents cheated out of the Medicare benefit they earned. By signing up, they completely relinquish control of their care to a private insurance company. I am furious that my company is even considering allowing this to happen. Is this legal?

igloo572 May 2015
Hmmm - I'm trying to figure out why a Medicare Advantage plan would find any financial benefit to get those in a NH to sign up? If the facility you work in takes Medicare AND Medicaid, I'd bet 60% maybe 70% of the residents are duals on those so have no need for a Advantage plan in the first place as between the 2 they pretty well have total coverage. maybe a prescription or two that falls through but those get written off as they are impoverished to qualify for Medicaid. Also most probably aren't cognitive enough to sign off on legal documents.

Now if this is a totally private pay facility, then that's a whole other situation and there's gold in those hills. My mom was in IL a tiered facility that ran from IL to AL to NH and a hospice wing - only the NH took Medicaid; when she was in IL, on a regular basis there would be a speaker on annuities; advantage plans; investments (not stockbrokers either but always insurance agents); endowment giving to the foundation affiliated with the facility. Really the residents were pigeons for the salesmen.

My first thought is there is some relationship between the DON and whomever is the insurance agent? could that exist?; Second thought is the plan salesperson or agent is also related to someone who is also an owner of the facility - this done by corporate or LLC ownership to get around Stark Law violations.

If you are really concerned that there is coercion happening, I'd quietly ask whomever is the Area of Aging ombudsman for the facility to come to the meeting and sit in on the presentation. You could also set your phone to record the meeting as well.

DennisByron May 2015
There are very strict rules about how Medicare Advantage is marketed, one of the most basic being a variation of "you have to call them." That being said, on Medicare you have completely relinquished your rights to a private insurance company no matter what type of Medicare you have -- fee for service or capitated fee. The benefits are actuarially the same and the appeals processes are basically the same. And of course Medicare does not cover nursing home charges anyways so what you describe does not sound different than an insurance agent going into a senior center, which happens all the time

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