Nursing homes and Medicare?

LizG55

Hi all,

 Can anyone tell me if what I heard is true. I know that when you've been in a hospital and then you go to a skilled nursing facility, Medicare pays up to 100 days. But a few people have told me that if you are in an ALF and you can no longer bear weight, then you have to go to a nursing home (skilled nursing facility).. but that if the doctor writes an order, you get the 100 days... Medicare not Medicaid I am taking about...

Thanks much...

towhee

Do you have to go to nursing home if you cannot bear weight----It depends on your state regulations and then the individual facilities capability.  

Can doctor write order for Medicare to pay for nursing home without being admitted to hospital-----No     Maybe 40 years ago, not now.

To get rehab in nursing home--- You must be admitted to hospital for 3 nights, truly admitted, not just in a room, they can be sneaky. Then a doctor can order rehab in a nursing home, where you will get as much time as the insurance co thinks is necessary, very,very rarely is that 100 days. If you discharge from hospital to home or AL and within a certain time frame say you need rehab(30dsys?), a doctor can order rehab in a NH. 

You can try asking your area agency on aging, or a social worker at a facility for info

Jo C.

Hello Liz, there are special rules regarding being able to obtain Skilled Care through Medicare insurance.

First; in order for a person with Medicare to receive Skilled Care in an inpatient skilled care setting, the person must have been in an acute hospital for three 24 hour days as an inpatient.  This is important as a patient can be admitted to a hospital as an outpatient even if they are there for a couple of weeks - always check the status to ensure inpatient admission when a Loved One is admitted to the hospital.  Ask the doctor to write specifically for inpatient status, and then check each day with the admissions department to ensure the patient continues as an inpatient as inpatient status can be changed to an outpatient status retrospectively - a person is supposed to receive written notice of such a change, but always good to check.

The patient will also need a doctor's order for such care and must fit Medicare criteria for medical necessity for admission to Skilled Care.

If a person is on a Medicare Advantage Insurance Plan, the plan can choose to waive the three 24 hour day hospital stay.

As for length of stay, though there are 100 lifetime Skilled Care days per benefit period, the average length of stay is approximately 21 to 30 days, give or take a bit.   Rarely does anyone require 100 days of Skilled Care at one time. One can recover some of the 100 lifetime days used; more about that later.

The patient must be able to cooperate and be actively and consistently able to work with the Skilled Care modalities and the needed care must be unable to be provided in an outpatient setting or in the home.

The patient as said, must be able to work with daily rehab and be able to understand, follow and retain the rehab information.   If cognitive impairment leads to insufficient memory to learn and follow, or to retain, or to refuse the rehab, it may be that the person will be discharged due to lack of ability to work with the care or refusal to work with the program.

If a person is on regular Medicare, then Medicare pays for the first full 20 days in Skilled Care.  After that, there is a co-pay.  If one has a supplemental policy, it will usually pick up the cost of the co-pay.  If one does not have a supplemental policy, then the patient will be financially responsible and in 2022, the co-pay is $194.50 per day.  A patient in an Advantage program will have to check if there is an co-pay as it can be different from program to program.

Care is offered in a "benefit period" of 100 lifetime days per period.  When day are used, they are subtracted from the lifetime number of 100 - but those days can be won back under certain circumstances.  Another benefit period will begin IF the patient is out of all SNFs and acute hospitals for 60 full days.  The new benefit period would start on the 61st day.  However, say a person has spent 20 days in Skilled Care and goes home for say, 30 days but returns to the hospital; then goes to Skilled Care again after discharge, the count against the 100 day benefit period begins as day 31 as  the patient had not been out of a SNF or acute hospital for 60 full days.  If not readmitted for 60 full days and has been out of SNF and acure care during those days; the prior used days are cancelled and the 100 days are back in place again.   It can be confusing and most people are unaware of this.

When one has a new benefit period, the criteria for that three 24 hour acute hospital admission once more begins.

I know it is complicated and disappointing in some ways.  There is also alot of information about this on Google.

Hope this information was helpful.

J.

Jo C.

Hello Liz, there are special rules regarding being able to obtain Skilled Care through Medicare insurance.

First; in order for a person with Medicare to receive Skilled Care in an inpatient skilled care setting, the person must have been in an acute hospital for three 24 hour days as an inpatient.  This is important as a patient can be admitted to a hospital as an outpatient even if they are there for a couple of weeks - always check the status to ensure inpatient admission when a Loved One is admitted to the hospital.  Ask the doctor to write specifically for inpatient status, and then check each day with the admissions department to ensure the patient continues as an inpatient as inpatient status can be changed to an outpatient status retrospectively - a person is supposed to receive written notice of such a change, but always good to check.

The patient will also need a doctor's order for such care and must fit Medicare criteria for medical necessity for admission to Skilled Care.

If a person is on a Medicare Advantage Insurance Plan, the plan can choose to waive the three 24 hour day hospital stay.

As for length of stay, though there are 100 days per benefit period, the average length of stay is approximately 21 to 30 days, give or take a bit.   Rarely does anyone require 100 days of Skilled Care at one time.

The patient must be able to cooperate and be actively and consistently able to work with the Skilled Care modalities and the needed care must be unable to be provided in an outpatient setting or in the home.

The patient as said, must be able to work with daily rehab and be able to understand, follow and retain the rehab information.   If cognitive impairment leads to insufficient memory to learn and follow, or to retain, or to refuse the rehab, it may be that the person will be discharged due to lack of ability to work with the care or refusal to work with the program.

If a person is on regular Medicare, then Medicare pays for the first full 20 days in Skilled Care.  After that, there is a co-pay.  If one has a supplemental policy, it will usually pick up the cost of the co-pay.  If one does not have a supplemental policy, then the patient will be financially responsible and in 2022, the co-pay is $194.50 per day.  A patient in an Advantage program will have to check if there is an co-pay as it can be different from program to program.

Care is offered in a "benefit period" of 100 days per period.  Another benefit period will begin IF the patient is out of all SNFs and acute hospitals for 60 full days.  The new benefit period would start on the 61st day.  However, say a person has spent 20 days in Skilled Care and goes home for say, 30 days but returns to the hospital; then goes to Skilled Care again after discharge, the count against the 100 day benefit period begins as day 31 as  the patient had not been out of a SNF or acute hospital for 60 full days.

When one has a new benefit period, the criteria for that three 24 hour acute hospital admission once more begins.

I know it is complicated and disappointing in some ways.  There is also alot of information about this on Google.

Hope this information was helpful.

J.

LizG55

Towhee...

according to the state yes, according to the facility no.. but only the group homes might allow you to stay. that's what I know so far.... since he is on Hospice. 

OK on the doctors note and Medicaid. 

Yes I understand about the rehab and Medicare.. been there with that already... thank you for replying and your info

LizG55

Hi Jo..

Sorry it's taken me a bit to get back craziness here. His and mine for that matter is a Medicare Advantage plan.  Thank you for ALL that info, I have to digest it.... read it a couple of times already. I get told different things by different people..  Maybe I should call Medicare? Also his insurance company?  I was told by Hospice he really needs a skilled nursing facility that I should admit him to that! However, having seen many ALF's he could go into an ALF as they tell me now but once he cannot bear weight at all since his walking is fragile, he might have to be transferred to a nursing home from the ALF because that's what the skilled nursing homes are and they are terrible here ...horror stories from my poor father and what happened to him. Also the Hospice nurse said the same try to keep him out. So I have been looking at group homes and there are differences in them..and what they will and will not do.  Meantime I'm caring for him. I don;t want him to endure what my father did for sure,

But I suppose this week I need to call Medicare and his insurance and find out for certain. 

As always you are a diamond! Thank you so much,... yes the system is so confusing, I did speak to an attorney that handles the Medicaid business but that is a whole other story and might not be worth it at this late date. His fee is very very high about close to private pay in a nursing home for one month and then there is all the paperwork I would have to get him which could take couple of months.. so between that and his processing plus the system itself and  time might run out for my husband.. he pointed that out.. but if I decide to try and put him on medicaid to let him know.  He was given a 4 month time frame of life. Who knows really though,.. things change..to me he's better than he was...it's minute but even so... so been very overwhelming here..... again thank you...

Jo C.

Liz; the information I proved was for Skilled Care Rehab; not for nursing home care.  That is very different.  In custodial care, there are no 24 hour days involved and Medicare does not pay for any days in nursing home care as it is custodial care.

NOTE:   You do not need an attorney to apply to Medicaid for you - you can do that yourself. I have actually done it twice.  The forms must be filled out completely, but that is no problem.  You will have to provide copies of different required documents as you already know; that is the most difficult part of it, digging those papers all up.  The attorney fees sound astronomical . . . and you will have to do the hardest part of the work; finding the documents to acompany the application.  I peronally would not pay high attorney fees to have the office make the application - it will not get processed any faster than if you filed the application yourself.

IMORTANT:  The most important thing to avoid delays is to ensure the application has been completely and fully filled out; nothing skipped and that you have enclosed all  the various documents collected.  It takes anywhere from one to two months for the application to be processed, so there is that little wait.

It does sound as though your husband's injury will not be a good fit for an ALF at this time; it is good to discuss facilities with your Hospice RNs and Social Worker; they often ave good information.  Hospice can follow the patient even when in a Nursing Home.

You might want to contact your Advantage Program and find out if they have any special benefits that may fit your husband's needs.  Some Advantage Programs will have a variety of different ways of approving benefits.

J.

jfkoc

Do you happen to have  Long Term Care insurance?

LizG55

Hi Jo...

So the head mgr from the Hospice told me a skilled nursing facility here is also a nursing home what can I say. This Hospice nurse confirmed that. I hear what you're saying and being told different things, Hospice here is very poor. They only have a social worker twice a week for the whole Hospice that is in this county. It's insane, I can't get her. I feel like I have no direction except for the alz association as Hospice is not always telling me the real deal and often makes mistakes.

OK on the Medicare given wrong info then on that too. 

As far as doing the paper work for Medicaid yourself, since as you say it is me doing most of the work anyway.... where do I get those forms? Can you give me some direction there. I have a list from the attorney's website of what I need to put together. 

The Hospice RN plus the head nurse said to me they are not allowed to recommend facilities with me... except to give me a list and then I;m on my own to figure out where to go,. I never got the list that was last week. There are only two Hospice's as far as I can see in my county.  I've called the other one also, never gets back to me..

I have not called the insurance company yet or medicare as you know.... '

Ugh.... Thank you Jo...

LizG55

No  don't have Long Term Care Insurance

Jo C.

Sometimes the term, "Skilled Nursing Facility," will be meant to be a custodial care nursing home.  That confuses things as it is also used to denote Skilled Care in a rehab format.  If you use Google, you can find a lot of information regarding the difference between Skilled Care Facilities and Nursing Homes.   Continuing to use the same term for both types of facilities is confusing to families, especially when done by clinical individuals.

As for how to find the form for Long Term Care Medicaid, I do not know what state you are in.  What I did when needing an application form, was to contact my state's Medicaid Office.  You can find the contact number for your state's office using Google; it will be listed.  Just be sure that when you reach the number, that you ask to speak to a representative for LONG TERM Medicaid for custodial care.  Big difference between that and regular Medicaid.

The Area Agency on Aging can often be of assistance as where to find things.  If a person is admitted to a Nursing Home as "Medicaid Pending," the Social Worker will usually assist in application. Sometimes one cannot get admitted as a "pending" patient; nursing homes have been hurt by having people admitted as pending and then fail to be approved and have no way to recover the costs of the patient's care.  BUT . . .

If a person can afford to pay for one or two months of care, paying for one month up front proior to admission, many facilities will approve the admission.  This is because, if a person does not successfully get approved for Medicaid, the facility has the money in hand for the cost of caring for the patient and if the money cannot be found to keep the patient, then the patient must be discharged or transferredd out.  NOTE:  In all or most states, IF the family pays for some months up front for admission while the application is pending; IF the application is approved, then the family is reimbursed for up to three months of whatever payment had already been made to the care facility. That happend with us. I had paid for two months up front, and when my LOs application was approved, I was reimbursed for the two months paid. 

NOTE:  If you think you will pay up front while applying for Long Term Medicaid Benefits, do be sure to find out whether or not this reimbursement is also done in your state.

Federal law has time limits for how long Medicaid can take before approving or not approving the application.  For disabilities, I think it is 90 days; for other apps, it is I believe, 45 days.

Be very sure the application you obtain and send back is for LONG TERM Medicaid.  Anything else will not pay for long term care.   Make a a copy of your completed form and all documents you have sent in.  I sent the application and documents by Certified Mail through the Post Office so I would have proof the Medicaid Office had received it.  (I am so overly cautious, that I made a copy of the application and filled it out as a "practice," once done, then I filled out the actuall application to be sent in.  It actually was helpful and had no errors on the app to be sent in.)

One can, in some states, make application online, but I did not have that option and if I had an option for that, would probably have sent it by Certified Mail instead so all documents were with it.

NOTE:  Also; when speaking to the Medicaid office, ask them for a list of specific information for just what documents will be needed to accompany the application. 

An application will be processed without a glitch IF the application is fully and completely filled out AND if all the required documentation is present with the application.  If that is not done, then there will be delays in processing and approval.

As said, I have applied twice for two different LOs and all went smoothly.

I thought it would be difficult to obtain the banking statement information going back for several months, but the bank had it to me almost right away.  Each state is different in how many months back they want to see such statements.

There will be other documents necessary for the application process, just be patient and put one foot in front of the other as sometimes we must do a bit of searching. As said, you would have had to find all the supportive documents whether you do the application yourself or an attorney does.

Best of luck; just have patience, so not let yourself get overwhelmed or agitated with this - you can do it or if you want to, you can have an attorney assist if you feel that is best for your situation.

J.

JJAz

Medicaid is NOT a "do it yourself" situation, unless you want the worst outcome (in terms of spending all of your money).  Instead, you should contact a Certified Elder Care Attorney (CELA).  This is what they do.  They will ensure that you are able to keep as much of your assets and income as is LEGALLY possible when Medicaid is involved.  Should you insist on doing this yourself, call the local Area Agency on Aging.  There is one in every county in the US (they may have a different name).

Most SNF (skilled nursing facility, aka nursing home) patients go there for a brief stay after a hospitalization (3-5 days).  In these cases, the SNF functions as a step-down unit.The confusion regarding 100 days of Medicare in a SNF is common.  Yes, there is 100 days of coverage for Medicare patients.  But during those 100 days, a patient has to be recertified (typically every 5-10 days) that they are still benefiting from the rehab aspect of the facility.  The rules for recertification are very strict with Medicare.  Most elderly patients are not recertified more than 1-2 times before they are given discharge notification. 

Jo C.

I went back and amended my last Post to better explain the 100 Skilled Care Days as "lifetime" days. That is important.

J.

LizG55

Jo.. thank you. I'm pretty well on my own with this unless I hire the attorney. But as you said, I'm doing all the researching paper work as it is.  I'm taking it one step at a time as that is all I can do. Understand about filling out the paperwork properly to avoid delays.  Nightmare  of a health care system...especially when you are disabled yourself. We do not have the help of other areas. We don't have the county services department not the counsel on again here and they were a waste!!!!!  of my time waited 2 months for the appt and we spoke.. but I need to get some info for her she never called me back at the scheduled time. I'll probably drop dead before any of all this is done the way the lack of help except for the Alz assoc, you, and some other folks (caregivers) have given me....  I mean I have more to do than just this... my days are little sleep mostly work.  I know this is no unusual but I am health compromised..and have already crashed once. It's a ridiculous system...

Thanks much,

LizG55

I did twice. speak to AElder Care Attorneys who knew nothing of what I was talking about, .... and finally was directed after several months to the attorney who does know the ropes for this his fee is $7500.00... I have his list on what I need to put together.  Otherwise thanks for the info, I know after a hosptialization often have to go to skilled nursing we have up to 100 days they usually recertify if necessary. For this scenerio though it sounds like Medicare is out.. and I need to get the Medicaid deal going.  Thanks again,

JJAz wrote:

Medicaid is NOT a "do it yourself" situation, unless you want the worst outcome (in terms of spending all of your money).  Instead, you should contact a Certified Elder Care Attorney (CELA).  This is what they do.  They will ensure that you are able to keep as much of your assets and income as is LEGALLY possible when Medicaid is involved.  Should you insist on doing this yourself, call the local Area Agency on Aging.  There is one in every county in the US (they may have a different name).

Most SNF (skilled nursing facility, aka nursing home) patients go there for a brief stay after a hospitalization (3-5 days).  In these cases, the SNF functions as a step-down unit.The confusion regarding 100 days of Medicare in a SNF is common.  Yes, there is 100 days of coverage for Medicare patients.  But during those 100 days, a patient has to be recertified (typically every 5-10 days) that they are still benefiting from the rehab aspect of the facility.  The rules for recertification are very strict with Medicare.  Most elderly patients are not recertified more than 1-2 times before they are given discharge notification. 

LizG55

Jo or anyone,...

Is there anyone to help with the paperwork for Medicaid besides the expensive lawyer?

MaryG123

I would check with your local library, area council on aging, or senior center.  They might know of someone who can help you LizG55.

jfkoc

We might be able to make better suggestions if we knew what state you are in.

Jo C.

Does your state have County Social Service Offices?   Well run senior centers? How about reaching out to your Area Agency on Aging . . .  Since we do not know what state you are in, you may find assistance for where to find such an entity at those places.

Social Workers at NHs also help fill out forms for patients that have been admitted to their facilities;  they may have referrals to local places to assist - just be sure you mention it is for LONG TERM CARE Medicaid which is totally different from regular Medicaid.

There are businesses that offer to help fill out the forms; I see them online, but have no idea what they charge.

What state are you in?
 

 J.

JJAz

MaryG123 wrote:

I would check with your local library, area council on aging, or senior center.  They might know of someone who can help you LizG55.

 

Think about spending money for an attorney this way.  If you need Medicaid for long term care, you will be required to spend-down most of your assets before you qualify.  You can spend-down your assets by paying an attorney to get the best advice possible or you can spend-down your assets by paying the nursing home.  Either way, you are spending down assets.