Updated: September 07, 2021 06:45 PM
Created: September 07, 2021 05:10 PM
ROCHESTER, N.Y. (WHEC) — News10NBC is investigating the story of a nursing home getting an elderly resident to cancel her private insurance without warning her family.
In this case, it was an 80-year-old woman in rehab recovering from COVID.
The insurance rules say this could happen to anyone who is Medicare-eligible and goes into a skilled nursing facility.
"I was very worried my mother wasn't going to have insurance at all," Marianne Licorish said.
In the spring, Licorish's mother, Janice Lorback, found herself inside the Brighton Manor Nursing Home near Our Lady Mercy School for Young Women.
Lorback had just spent two weeks at Strong Memorial Hospital with COVID. The hospital sent her to the nursing home.
As a retired public employee, Lorback had Medicare Advantage insurance.
That’s Medicare but a private policy through an insurance company, in this case, Excellus Blue Cross Blue Shield.
When Lorback arrived at the nursing home, her daughter said she was given a cognitive test and then documents to sign.
"They had my mother sign a piece of paper. She's an 80-year-old woman with underlying conditions trying to recover from COVID. And the first day she was in there they had her sign a piece of paper," Licorish said.
"Like I said, when I got there I was sick," Lorback said. "I did not know what I was doing."
By signing the documents, Lorback dis-enrolled herself from her Medicare Advantage insurance and automatically went on basic, government Medicare.
Licorish says she's been contacted by doctors and nursing homes about her mother in the past.
Brean: "Did anyone at the nursing home contact you or your brothers to say - hey this is what we're going to do?"
Licorish: "Nobody. Nobody contacted us."
Brean: "When you talked to the nursing home, did they explain why they did this?"
Licorish: "They only thing they told me was that on my mother's health plan she gets 20 days in a rehab facility before they have to start justifying why she needed to stay there longer. So I think it's a lot more paperwork for them."
"It should not have happened without her clear understanding and consent," Judith Stein said.
Stein is the executive director of the Center for Medicare Advocacy.
Brean: "Why do you think the nursing home would do this?"
Stein: "I suspect there is some pressure from the Medicare Advantage plan. I suspect at the very least it is more of a hassle to deal with the Medicare Advantage plan."
By law, Medicare Advantage must provide the same coverage as basic Medicare including up to 100 days of rehab and a copay after day 20, but Stein says nursing homes can get pressure from Medicare Advantage plan operators that they don't get from basic Medicare.
"We hear very often that after 14, 20, a certain number of days Medicare advantage plan directors, leaders, whoever is in charge there starts to contact the nursing home and encourage them if you will to stop the Medicare coverage," she said.
After several attempts to contact the nursing home, its out-of-town owner and his lawyer, I was contacted by the company that manages the nursing home.
In July, two months after Lorback left the nursing home, the Grand Healthcare System took over operations and changed the nursing home's name.
The company declined an interview but in a statement said "Both traditional Medicare and managed Medicare require ongoing justifications for certain treatments. Our staff doesn't discuss changes in health plans for their convenience... These are Medicare rules, not provider rules."
If the plans are the same I asked the management company — Why do it in the first place?
Grand Healthcare did not offer an explanation.
Excellus does not talk about individual customers.
In a statement, a spokesperson for the Centers of Medicare and Medicaid Services wrote: "It is unacceptable for nursing facilities or skilled nursing facilities (collectively, long-term care or LTC facilities) to disenroll beneficiaries from Medicare Advantage plans without the beneficiary's or the beneficiary's representative's request, consent, knowledge, and/or complete understanding. Only a Medicare beneficiary, the beneficiary's legal representative, or the party authorized to act on behalf of the beneficiary under state law can request enrollment in or voluntary disenrollment from a Medicare health or drug plan."
Licorish said she only discovered her mother's Medicare insurance swap when, after her mother was discharged, she tried to buy her a pair of therapeutic, diabetic shoes. Licorish says, based on previous purchases, she was anticipating a $40 copay. When the cost was $140 she knew something was up and then found a letter from Excellus alerting her to the disenrollment at her mother's apartment.
It took Licorish six weeks to get her mother's old insurance back.
How is this allowed to happen?
Any time a person goes into a skilled nursing facility, a special enrollment period automatically starts. Judith Stein from the Center for Medicare Advocacy says that decision is up to the resident, not the nursing home.
Here's the key for families: The special enrollment period resumes when a person is discharged so they can get their old insurance. But if no one knows about it, you wouldn't know to do it.
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