Federal Probe Reveals Top Medicare Advantage Insurers Frequently Reject Nursing Home and Rehab Coverage
The largest private Medicare Advantage insurers—including UnitedHealth Group, CVS Health’s Aetna, and Humana—are significantly more likely to deny initial coverage requests for nursing home stays and specialized rehabilitation facilities, according to two new reports released by the federal government.
A new investigation conducted by the Department of Health and Human Services Office of Inspector General found that these massive insurance providers maintained initial denial rates of roughly 13% for standard nursing home care.
The figures were dramatically higher for more intensive medical care, reaching initial rejection rates as high as 80% for patients seeking admission into long-term-care hospitals and inpatient rehab centers.
Lead investigators voiced deep concerns that private insurers are systematically blocking seniors from accessing medically necessary treatments to control costs.
Under standard traditional Medicare, patients automatically qualify for nursing home coverage if they require skilled nursing or therapy following a hospital stay of three or more days, generally without needing advanced approval.
However, because private Medicare Advantage plans actively manage care, seniors must navigate rigid prior authorization rules.
Insurance representatives defend the practice, claiming preapprovals prevent unnecessary medical services and ensure consumer safety, while federal regulators vowed to increase oversight to force compliance with coverage standards.
