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I am confused about Medicare, Medicaid and Private Insurance benefits. Where do I start?

Asked by caremom1 | Jul 15, 2010

My mom is in skilled nursing, will need transfer to another one long term. She has a good private health insurance through AARP, no long term care insurance and can't return home to live due to medical issues that have developed since a stroke. She has recently developed pneumonia as well.

I keep hearing about "100 days" and a patient is out of skilled nursing with medicare. Medicaid sounds like a nightmare, financially and other wise. We live in California and I don't even know where to start with the idea of what to do next.

Any experience with this? Suggestions?
Thanks!

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K. Gabriel Heiser, Jul 28, 2010

K. Gabriel Heiser is an attorney with over 25 years experience in elder law and estate planning. Heiser is the author of "How to Protect Your Family's Assets from Devastating Nursing Home Costs: Medicaid Secrets," an annually updated practical guide for the layperson. Visit www.MedicaidSecrets.com for more info.

Hi: I discuss this in my book:

Medicare Coverage of Nursing Home Expenses

Many clients are under the mistaken impression that Medicare will cover their long-term nursing home stays. If you give seminars or in client meetings, it is important that you educate the lay public about this.
In order for Medicare to cover a person’s nursing home stay, the patient must:
1. Have been hospitalized for medically necessary inpatient hospital care for at least 3 consecutive days, not counting the date of discharge,
2. Be admitted to the nursing home within 30 days after the date of discharge from the hospital,
3. Require skilled (as opposed to custodial) nursing or rehab care on a daily basis for a condition for which the patient was hospitalized, and
4. Receive a physician’s order that such care is needed.

Skilled Care. Skilled care is care that can only be administered by professional (physician or nurse) or technical personnel and which will prevent further deterioration in the patient’s health. Examples are intravenous feeding, injections, insertion of catheters, application of sterile dressings, treatment of skin ulcers, and therapeutic exercises of various kinds. Less medically intensive and critical personal care services, even if done by a nurse, are not considered skilled care.

100-Day Limit. Once in the nursing home, the patient will only be covered by Medicare for a maximum of 100 days during any spell of illness. A “spell of illness” means a period of consecutive days beginning with the first day (not included in a previous spell of illness) on which such individual is furnished inpatient hospital services, inpatient critical access hospital services or extended care services, and which occurs in a month for which he is entitled to Medicare Part A benefits, and ending with the close of the first period of 60 consecutive days thereafter on each of which he is neither an inpatient of a hospital nor an inpatient of a nursing facility.

Co-Pay Rule. Finally, even if the patient manages to qualify for Medicare coverage of their nursing home stay, Medicare only fully pays the bill for days 1-20. For days 21-100, Medicare only pays the “SNF care coinsurance” amount, which in 2010 is $137.50 (set annually by the federal government).
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Hope that helps!
K. Gabriel Heiser

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lt7481

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Jul 28, 2010

Could someone please address the pros and cons of applying for medicaid. my mother has medicare and AETNA and is being advised to apply for medicaid. Please advise. Thank you.

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lt7481

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Jul 28, 2010

thank you

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caremom1

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Jul 28, 2010

Mr.Heiser-
Thank you for taking the time to respond. My mother contracted pneumonia ,swollen right extremities and developed skin ulcers in the nursing home.Mild heart failure was diagnosed on the Xray which showed no progress was being made with curing the pneumonia. So, my mom started out in the facility because of rehab needs after a stroke and now there are many complications to both general health and viable rehab progress.
Does she need to be reevaluated and diagnosed with multiple needs for"skilled" nursing?
If she left skilled nursing, went back to the hospital for 4 days for heart failure then back to rehab would the 100 days start again?
Any suggestions are very much appreciated.
Thanks again for sharing your expertise.
Kim(caremom1)

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