Humana, Aetna, United: Same Resident, Different Rules
Medicare Advantage is often talked about as if it’s a single payer category. For skilled nursing teams doing the work every day, that framing doesn’t hold up.
Humana, Aetna, United — the same resident, the same care, and three very different sets of rules. Documentation expectations, level-of-care criteria, and reimbursement logic can shift meaningfully depending on the plan. Over time, that variation creates real friction for reimbursement and clinical teams trying to stay aligned while managing lean staffing models and increasing census.
One regional reimbursement leader described it this way: “We’re constantly stopping to ask, ‘What plan is this again?’ And then we’re double-checking whether what we documented actually matches what that payer expects.”
That hesitation is telling. It’s not a lack of expertise. It’s the reality that Medicare Advantage has become highly plan-specific, and most workflows were never designed for that level of nuance.
In many organizations, plan rules live in people’s heads, spreadsheets, or informal reference guides. Intake flags the payer, teams do their best to remember the differences, and additional chart review gets layered on when something feels off. That approach works initially, but breaks down as scale increases.
As residents’ conditions change between reviews, documentation lags behind care delivery, or different team members step in mid-stay, alignment can quietly slip. The result isn’t always a denial. More often, it’s care that meets skilled criteria but isn’t fully reflected in the way a particular plan expects, or conservative decisions made simply to avoid risk.
Leaders at Windsor House saw this firsthand. Managing Medicare Advantage across multiple communities, differences between plans like Humana and Aetna made it difficult to maintain consistent level-of-care alignment without adding more manual work for already stretched teams.
This is where technology can make a meaningful difference, not by changing how care is delivered, but by making plan expectations visible as work is already happening.
With tools like MedaSync, documentation from nursing, therapy, and providers is continuously viewed through the lens of each specific Medicare Advantage plan, supporting plan-aware Medicare Advantage oversight without adding manual work.
At Lionstone Healthcare, improved Medicare Advantage performance didn’t come from working harder or adding oversight layers. It came from having clearer, day-to-day visibility into how individual plans viewed the care already being provided, as outlined in this Medicare Advantage case study.
Medicare Advantage isn’t getting simpler. Plan variation is increasing, not shrinking. And treating MA as “one payer” is becoming harder to justify operationally.
The organizations managing it best aren’t asking their teams to memorize more rules. They’re finding ways to make those rules visible, plan by plan, as part of daily work.
If Medicare Advantage plan variation is creating uncertainty or extra work for your team, it may be time to look at a more plan-aware approach.
Learn how MedaSync helps skilled nursing organizations bring clarity to Medicare Advantage oversight without adding manual burden.
