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The son of a hospitalized patient recently called the Center for Medicare Advocacy. His father was ready for discharge. Physicians at both the hospital and the inpatient rehabilitation hospital (IRH) agreed that the patient would benefit from IRH services. However, the patient’s Medicare Advantage (MA) plan refused to authorize IRH care.  The plan instead said it would authorize one week’s stay in a skilled nursing facility. The plan also refused to give the son a written notice from which he could appeal. All communication with the plan was oral. The son called 1-800-Medicare, and was told they could not help with issues involving a Medicare Advantage plan. [1].

There are no good answers for this family.

The patient could disenroll from the Medicare Advantage plan and return to traditional Medicare, but disenrollment would not be effective until the first day of the following month. Further, whether a disenrolling beneficiary is eligible to purchase a Medigap plan to cover copayments and deductibles in traditional Medicare depends on the beneficiary’s state of residence. It was unlikely in this patient’s state.

The patient could file a complaint with the state insurance commissioner about the MA plan’s refusal to give him a written notice, but any resolution would not affect his immediate need for appropriate post-hospital care.

The patient could contact his Congressional representatives, but, again, any assistance they could offer would not affect his immediate need for appropriate post-hospital care.

Once again, another Medicare Advantage enrollee in need of serious care found himself stuck in a frustrating maze that did not lead to the care he needs.

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[1] We find that high-need and dual-eligible enrollees have substantially higher disenrollment rates when compared with non–high need enrollees. This finding aligns with that of the recent Government Accountability Office report on disenrollment and other recent examples from the literature that suggest that MA plans may not currently meet the preferences of high-need enrollees. See, eg https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2725083.

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