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I realize coverage differs according to many factors, but just wondering if anyone might have some thoughts. My mother has Medicare/Oxford in NY State. She is almost on day 21 of being in sub-acute rehab after a stroke. Last week, we met with her "team" and the SW said she would probably be discharged at the end of June. She explained that Medicare covers 21 days at 100 percent, but then we'll have a co-pay of $142/day and then it costs $500 a day out of pocket. But today, her PT told me she is going to ask for a longer session per day with my mom (55 min vs 30 min) because she shows a lot of promise. We had a cryptic conversation over my mom's wheelchair in which I asked if that meant a longer stay and if Medicare would cover it plus extra PT time. The PT said she was going to look into it and was prepared to appeal if necessary. I'm completely confused about how this all works! My main concerns are: How long can she stay there and how much will everything cost? I left a message for the SW to get clarity on everything, but I haven't heard back from her yet.

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It's all in the verbiage from the Therapist / Dr. There need to be a two way conversation that is specific with your wants and needs so the therapist and you are on the same page to get whomever the necessary care.
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No, not liable. Here's the thing=they were kicking my mother out because they deemed her too well to stay there. We had put down a large chunk of change down on an AL. Then less than 48 hours after they said "mom, you can't stay at the NH," she suffered a stroke there!!
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I know, but I believe they are liable when they discharge someone. Is that right? I know the hospitals are liable when they release someone.
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First and foremost SNH's are businesses Thus, they run it as such.
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What kind of liability does the SNF have in terms of discharging her? What if we need time to set her apartment up safely with a hospital bed and other equipment? Or what if she's on a waiting list for a bed at a long-term care facility?
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xinabess: No, we did not have time for any appeal. Both my mom's adult kids (me, who was the primary, out of state caregiver moved in with her to Massachusetts from my Maryland home) and my brother who lives in California. We just had to lay a large chunk of money down on an AL, who had a room and that I had checked out 4 months prior.
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I think the OT and the PT are generally the ones who have to go to bat for you in the appeal process. They have to say that there is a lot of progress being made and that further intense therapy (inpatient) will be worthwhile. And yes, the motivation on the part of the patient is very important. If she is just 'going through the motions' but not trying hard to do more every time, that makes a difference in what progress can be expected. Keep talking to the therapist, social worker and even administration. Administration has to tell you when medicare will quit paying, so you can make an informed decision on whether to keep your mother there or move her home or to another type facility. They have to tell you the exact day when it changes, otherwise, they cannot bill you for difference, or any additional costs. The maximum Medicare part A covers is 100 days per illness but it is very difficult to get that much coverage. You can get a lot of information at Medicare.gov website. But talking to your therapist, social worker and the administrators should get you the information you need. The whole process can be very convoluted. Good luck!
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I'm so confused about how this all works. Llamalover, what happened when your mom was kicked out? Did you appeal or find another situation for her?

I get that Medicare only covers X amount of time in rehab and that SNH is a business. I don't quite get how much say I have in trying to challenge Medicare and the SNH if they seem to be kicking my mom out. If they discontinue OT and PT services, then what? My mom's speech/language therapist has already stopped providing services because she says my mom has recovered a lot in that department, which is true. Another issue is that my mom is resistant to all of it. She'll do the PT and OT, but she's not exactly the most compliant person. How much does that figure into all of this?
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xinabess: The SNH is a business. The particular SNH my late mother was at (and we, as the family, wanted her to stay) was so slick that they had a family meeting...what a joke...the PT stayed all of one minute and said N (name withheld for privacy reasons) can walk xxx # of feet and then left the meeting! They were kicking my mother out. They were also kicking out another patient, who was a recent amputee and he didn't even have his prosthetic yet!
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You may have to call the SHIIP line at 1-800-443-9354. (senior health insurance information program) run by Medicare. (free) You also may have to call Oxford supplemental to see if they cover the copay.
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Thanks for the information. I understand the stuff about goals and plateaus. What I am not clear on is: does appealing mean you want more TIME for the person to get PT, OT, or stay in a SNF? Or are you also trying to get Medicare to extend how long they will cover 100 percent of the extra time? Is the amount of coverage something one can negotiate? I've been told that my mom gets 21 days of rehab covered at 100 percent. After that, there is a per-day co-pay of $142 for 100 days. Is it possible to get the co-pay period turned back into 100 percent coverage?
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Jimmo vs Sebelius reconfirms that even with in-home physical therapy, if steady progress is no longer evident but the client has more Medicare days allotted for in home physical therapy, the client has the right to continue with the goal of maintaining existing mobility.
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Sunnygirl: Medicare says that therapy goals can be set to return to previous level of function looking back to the previous year. So the answer is 'yes', therapy can be available to attempt to return a patient's function to independent transfers as long as she was doing that in the last year. However, the patient does have to make some type of steady progress toward that goal, which on an outpatient basis has to be re-evaluated every 10 visits.
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xinabess: All I can tell you is to be careful! These SNH's are slick and can "pull the rug out from under you" before you even realize it. What I mean is these facilities can be planning to evict your LO. This happened to my late mother.
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Please search the Jimmo v. Sebelius, the improvement standard case. It was a case settlement agreement settling once and for all that if there are Medicare days left for physical therapy, speech therapy, occupational therapy in any of these 3 areas: skilled nursing facility, home health, or outpatient therapy, the facility or agency cannot state "this client has reached full potential and so we are going to discharge them from our facility or agency." If the resident or the family or the Dr. want to continue just to "maintain" their current level of mobility the facility must comply until all Medicare day are used up.
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David W has it right. It's about the therapists seeing progress. Do ask about the goals they are charting for your parent.
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I hate to tail in on this question, but since you all know so much about this. Do you know Medicare's policy on rehab if the stroke patient has severe dementia and is in wheelchair at the time of the stroke? Would they cover enough rehab to get her to return to being able to transfer to and from the wheelchair again?
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It seems as though half the battle is learning the key word and phrases to use with the therapists and admin. You know what you want for your parent, but unless you know the "right" thing to say, their ears are deaf. These providers should be able to interpret patients needs into the appropriate medical jargon to navigate Medicare, but they are not as motivated to do that as a loved one is that is advocating for the patient.
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Also if situation deterorates consider Palliative care or Hospice care
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First of all, even if they (or anyone) tell you that coverage is ending, Continue to ask questions and never give up.
It appears that your mother just suffered this stroke recently and you are in the beginning stages.
Having consistent and ongoing therapy will (most likely) result in a better outcome for all. My mother had a stroke 6 years ago and we still get PT/OT/SP covered by Medicare. The trick is to A: Never give up B: Get educated C: Find someone who KNOWS the Rules, Guidelines/ and how the system works. (see links below). You would be amazed at how many professionals either don’t understand the rules or don’t want to (or know how to) “play the Medicare game”. My experience is this. Mom suffered stroke. Went to sub-acute rehab. She made decent progress during the 21 day period and then the administrator explained they would be discharging her. I had an “off the record” discussion with one of her OT’s who told me to “not follow the sheep” , meaning don’t accept the admins word that discharge was a Medicare rule. Since the Therapies were showing progress , Specifically, “ATTAINING GOALS”, the Therapists put in for exceptions to Medicare which were approved. If the staff mentions “Plateauing” that’s your first clue that discharge is the next step. Ask what “goals” your mom has reached and if they can chart a NEW GOAL. Without going into a great detail, Continue to define NEW Goals – Hint: Start with Small, attainable goals , that way you can Up the goal when they mention Plateauing. If you start with too hard of a goal, you have nowhere to go from there. Also, Ask now about Home Therapy. Immediately upon my mom’s discharge (to her own home) , we had therapists come to the home 2-3 times a week. (Medicare also covers limited in home care such as nurses visits , Durable equipment , etc.) Learn the terms & phrases that these Home Care Providers need to hear such as : My mom needs help with “ADL’s” (Activities of Daily Living).
NOW, Get in touch with Advocates [ AgingCare.com is a good start ] , Stroke.org Medicare Ombudsman https://www.medicare.gov/claims-and-appeals/medicare-rights/get-help/ombudsman.html
https://www.medicare.gov/Pubs/pdf/11173.pdf
I wish you and your mother continued success, improvement and good health.
All the best, David W.
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