Insurers Collected Billions From Medicare for Veterans Who Cost Them Almost Nothing
The Wall Street Journal / By Mark Maremont, Christopher Weaver, and Tom McGinty
Bruce Kitt is one of the Medicare Advantage industry’s most lucrative customers.
The federal government pays his private Medicare Advantage insurer thousands of dollars a year to cover the cost of doctor visits, hospitalizations and other medical care that the 74-year-old retired aircraft mechanic might need.
But Kitt, an Air Force veteran who served in Thailand during the Vietnam War, gets almost all of his healthcare outside the Medicare system, through the Minneapolis VA Medical Center. The taxpayer-funded Department of Veterans Affairs health system provides low-cost or free care to Kitt and about nine million other qualifying veterans.
Kitt’s Medicare Advantage insurer, an affiliate of CVS Health’s Aetna unit, pays for almost nothing other than a $100 monthly cash-like rebate to Kitt as an incentive to keep him on its rolls. The government paid the insurer at least $6,000 to cover him in 2022, the year he joined the plan.
“I don’t think I’ve used my Medicare in years,” said Kitt, who lives in Eden Prairie, Minn. When he needed some eye tests, the VA, not his Medicare Advantage plan, paid for him to go to an outside clinic. “I’m pretty happy with the VA,” he said. “I look at the Medicare plan as a backup.”
A Wall Street Journal analysis of Medicare and VA data found that Medicare Advantage insurers collected billions of dollars a year in premiums to provide medical coverage for about one million veterans like Kitt, even though they go to the VA for some or all of their healthcare needs.
The analysis found the insurers paid far fewer medical bills for those veterans than for typical members. About one in five members of Medicare Advantage plans that enroll lots of veterans didn’t use a single Medicare service in 2021, the Journal found. That compares with 3.4% of members of other Medicare Advantage plans.
The federal government paid insurers an estimated $44 billion from 2018 through 2021 to cover Medicare Advantage-plan members who were also users of VA services, based on average payments for all members of those plans. The VA spent $46 billion on the same group’s medical care, according to VA data reviewed by the Journal. The figures exclude pharmacy costs, which many Medicare Advantage plans focused on veterans don’t cover…
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Will Trump Reverse the Nursing Home Staffing Mandate? 3 Notes
Becker’s Hospital Review / By Elizabeth Gregerson
Nursing home officials said they are counting on the Trump administration to reverse an impending Biden-era staffing level mandate, KFF Health News reported Dec. 3.
About 40 states and nonprofits have sued HHS and CMS over a rule that, when implemented in 2026, would require long-term care facilities to have a registered nurse on site for 24 hours per day, seven days a week as opposed to the current requirement of eight hours per day, seven days a week.
In the lawsuit, the plaintiffs said the final rule "poses an existential threat to the nursing home industry as many nursing homes that are already struggling will have no choice but to go out of business."
Texas Attorney General Ken Paxton in August filed a similar lawsuit against the Biden administration over the mandate, a suit that was supported by the American Hospital Association in an amicus brief.
"Imposing inflexible numerical thresholds on long-term-care facilities will lead to worse patient outcomes and less patient-care capacity across the entire healthcare system," the AHA brief said.
KFF Health News spoke to nursing home industry insiders about what the incoming Trump administration might mean for the staffing level rule.
Here are three things to know from the report:
- "The Trump administration has proven itself really eager to reverse overreaching regulations. We think it's got a pretty good chance of being repealed, and hope so," Linda Couch, senior vice president for policy and advocacy at LeadingAge, one of the nonprofits suing over the mandate, toldKFF Health News.
- "Staffing is everything in terms of nursing-home quality. [If the rule is repealed] we would be losing that signal that nursing homes should try really hard to improve their staffing," R. Tamara Konetzka, PhD, a professor of public health sciences at the University of Chicago, told KFF Health News.
- "We're hoping the president-elect will come in and take a look at the science and data behind it and see this really is a modest reform. We'd be devastated to see it fall," Sam Brooks, director for public policy at the National Consumer Voice for Quality Long-Term Care, told KFF Health News.
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We Want Your Feedback About Proposed Changes to PCAFC
VA Caregiver Support
Dear Caregivers and Veterans,
We hope this message finds you well. We’re reaching out to share an important announcement. A Notice of Proposed Rulemaking has been published, which would expand access to the Program of Comprehensive Assistance for Family Caregivers (PCAFC) – an essential part of our Caregiver Support Program (CSP).
Through PCAFC, Family Caregivers of eligible Veterans have access to training, enhanced respite care, counseling, technical support, and beneficiary travel. Primary Family Caregivers can also receive a monthly stipend, CHAMPVA health coverage (if qualified), and access to legal and financial planning services.
Please note, the changes described are proposed changes only. No changes have taken effect at this time.
The proposed rule is now available for review, and a 60-day public comment period begins tomorrow. This is your opportunity to share your thoughts and feedback. VA will carefully consider all comments before finalizing the rule, which may change after comments are taken into account
Through the proposed rule, VA seeks to expand and clarify access to the program; reassess eligibility less frequently, reducing burden on Veterans and caregivers; and expand access to telehealth home visits in case of emergencies. Key Highlights of the Proposed Changes:
- Expanded Eligibility: A broader definition of serious injury could allow more Veterans and caregivers to qualify for support.
- Telehealth Flexibility: VA seeks to offer telehealth home visits during certain types of emergencies.
- Extended Delay in Discharges Based on Reassessments: This proposed rule would delay discharges based on eligibility reassessments for legacy participants, legacy applicants, and their Family Caregivers for an additional 18 months after the effective date of a final rule. The delay in discharges is currently slated to expire in September 2025. VA’s suspension of required annual reassessments, including legacy reassessments remains in place at this time.
- Fewer reassessments: Under the proposed rule, VA would reassess eligibility less frequently, lowering the burden for Veterans and their families.
- Eligibility Clarification: New criteria would expand and clarify the bases on which a Veteran may be determined in need of personal care services for six continuous months.
How You Can Get Involved: We encourage you to share your thoughts during the public comment period. Your voice matters and can help shape the future of this program. Please refer to our Frequently Asked Questions document for more information.
Thank you for your unwavering dedication and support. Caregivers are at the heart of our mission, and we’re here to support you every step of the way.
Your Caregiver Support Team |
National Alliance for Care at Home Welcomes Sherl Brand as New COO
NAHC Report
The National Alliance for Care at Home is proud to announce the addition of a proven leader, Sherl Brand, RN, BSN, who will be joining the Alliance as its first Chief Operating Officer (COO), effective in mid-January.
Sherl Brand comes to the Alliance with a wealth of experience spanning over three decades in nursing, association management, and health care management. Prior to joining the Alliance, Sherl has been serving as Senior Vice President for Hospice Care at VNS Health. Before that, Sherl held senior positions at CareCentrix and VNA Health Group. Sherl served as chair of the Forum of State Associations for almost four years, and as President and CEO of Home Care Association of New Jersey for seven years. She served on the Board of Directors of the National Association for Home Care & Hospice, the Medicaid Partnership for Home-Based Care, and the Home Care 100 Advisory Board.
“Sherl’s leadership experience and history of successful management of trade associations and home care and hospice organizations make her a perfect fit for the Alliance,” said Alliance CEO Dr. Steven Landers. “I see Sherl as the perfect partner to make sure the Alliance operational team is engaged and organized to ensure our treasured members receive amazing services and support. She has the knowledge and experience to lead our operations during this dynamic time for the Alliance and the care at home movement.”
“I am honored, and deeply grateful, for the opportunity to serve as the Chief Operating Officer of the National Alliance for Care at Home,” said Sherl. “I am privileged to have spent my career in our industry working with high quality organizations and a state trade association supporting providers of care in the home, and I look forward to working with the Alliance team to provide the world class education, conferences, and resources our members need and deserve. The future is bright for the care at home community. We are stronger together.” |
Expanded Long-Term Services are a Must, Study Authors Say
McKnight’s Long Term Care / By Kristen Fischer
Infrastructure to support long-term care services and aging-in-place for people living at home is sorely needed, according to a recent study. The report identified gaps to meet the needs of aging adults in the United States and help them maintain independence, the authors say.
By 2034, the number of Americans who are aged 65 and up will exceed the number of children under 18 for the first time ever. This will drive up demand for Medicaid long-term services and supports (LTSS) in home and community settings, the authors wrote.
Current home- and community-based LTSS offerings are not adequate to meet the needs of aging adults, and there are disparities in who can access the services. Though more people are shifting from nursing home care to home-based care when possible, the infrastructure for aging-in-place is still underfunded and fragmented, the researchers pointed out.
The report identified two main obstacles that will make it hard for many to get the Medicaid services at home: a lack of affordable services and lack of qualified healthcare personnel.
Recruiting and retaining healthcare workers, especially those in geriatrics, remains a top challenge in terms of long-term care and aging-in-place. In many cases, inadequate pay levels, difficult work environments and a lack of training make it hard to recruit and maintain workers, the investigators wrote.
Technology such as remote monitoring and telehealth can improve long-term care and aging-in-place, but it must be available in all areas, especially in rural regions. Additionally, the tools need to be distributed equally among all.
Additionally, though most adults over 65 receive Medicare, it doesn’t cover long-term maintenance services. This can force families to pitch in, resulting in more financial strain.
Although over 40 states have programs such as paid family leave and the Caregiver Advise, Record, Enable (CARE) Act to improve communication between healthcare providers and family caregivers, the policies aren’t used everywhere and don’t have enough funding. Authors of the report called out the need for policies to support caregivers and highlighted the potential benefits of integrating caregivers more fully into care teams.
The team promoted care models that can be scaled to meet growing demand such as the Program of All-Inclusive Care for the Elderly (PACE) and hospital-at-home initiatives.
“An integrated public health delivery system with full support for aging-in-place, such as increasing opportunities for home-based care, improving access to affordable housing, and providing solutions to satisfy older adults’ transportation and social participation needs will be critical to meet care needs of the aging population,” Katherine E.M. Miller, PhD, an assistant professor at Johns Hopkins Bloomberg School of Public Health, who led the team, said in a statement. |
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