I'm the medical proxy for a friend of 30+ years. She was diagnosed with locally advanced cervical cancer last month. She was in the hospital and discharged to a rehab facility while she continues to be treated with chemo and radiation.

The rehab facility is providing skilled care in managing chemo and radiation side effects, pain management, and with physical therapy. She is severely overweight and diabetic. She was just barely mobile prior to the diagnosis, and after a week or so in the hospital was unable to stand or sit unassisted. After a couple of weeks in rehab, she is now able to stand and sit up with assistance, and to use a walker to go about 5 feet.

Now the insurance (Horizon BC/BS) says she is not progressing quickly enough, and they are planning to stop paying for the rehab. Her own apartment is not appropriate for her now since it has too many stairs, among other issues. I saw the article "Does Medicare Cover Stays in Skilled Nursing Facilities, and noted the section "Debunking Medicare's Improvement Standard." I'm looking for advice on how to proceed with addressing this issue.

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I would suggest taking to her therapists at the rehab facility, they tend to have extensive knowledge about what will keep- a patient there and what will get them released, at least in my experience. Her therapist will know what is considered enough progress and what is considered too much (my mom was released because she was doing too well in some areas even though she wasn't in the areas she really needed). The type of rehab facility makes a difference too, she may qualify for a different level of rehab and that's the kind of info you should be able to get from the coordinator at the rehab she's in. They have a responsibility for her safety so if she isn't well enough to go home for whatever reasons (they may even send someone out to evaluate her ability to get in and out of the apartment) or be on her own they will be trying to set up help or another place and ask you questions as part of that effort. Be sure to be clear that you can't be around enough to see to her day to day needs and there is no one else, don't tell them you can do more than you can because it let's them off the hook and you want their help in making sure she has the help including PT she needs and that it's covered/affordable for her.
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mscherbina Aug 2018
Yes, I've talked with the people at the rehab extensively. Of course, now the insurance/Medicare people are changing their tune. The person who told me she wasn't progressing fast enough now denies having said that. She is now saying the patient doesn't need the resources of a skilled nursing facility, but should be in a custodial long-term-care facility, which of course Medicare doesn't pay for.

It's been made abundantly clear that the care she needs is far beyond what I or any of her other friends could supply.
So is she on original / traditional Medicare? & Horizon is her free standing secondary insurance?
is she on a Medicare Advantage or Managed plan with Horizon?
They are very very very different platforms for insurance.

Im going to guess it’s the latter, & if so, here’s my suggestions & why:
Managed care plans need to have you stay in network for Coverage to happen with no or a smallish copay. managed plans can cover out of network but limit days or $ amount and will have a huge copay. That rehab place is likely out of network.

Medicare & managed care plans exclude any long term care stays as it’s viewed as custodial care and not hospitalization or rehab. If she’s not progressing in her rehab or her rehab has “plateaued” then Medicare stops paying. As does the managed care plans as they go by Medicare standards. She is not progressing or has plateaued, it’s in her chart and likely entered daily or every other day. It’s fact based, so doing an appeal imo is a waste of time.

Before her hospitalization, she probably went to Hospital A & clinic B and basically all covered as the hospital, clinic, labs & all vendors under the horizon Bcbs insurance umbrella. All in network & all billing at a negotiated rate with Horizon.

What she needs to do imo is switch to original Medicare and apply for Medicaid. Forget fighting Horizon, she needs to do whatever to become a LTC resident at a NH. And that means she becomes a “dual” so on Medicare and Medicaid. It sounds like she realistically cannot go back to her old life and living on her own. If this rehab place is also a NH, there will be someone either with SW or admissions who have dealt with doing these. Ask.

She needs to get on this asap so that she’s not building up oodles of no insurance private Pay days billed. She needs to get that Medicaid LTC application done pronto so that she’s “Medicaid Pending”

Any idea how much $ she has in assets? Not her monthly income but any other $ she has, that’s her assets. She will need to spend down to get to 2K before Medicaid can be approved. Yeah 2k is the max for nonexempt assets. Find out and post and update as lots of us on this site have done legit spend downs for their parents. Please do not just have her give $ to anyone. Spend down has strict rules.

Her monthly income - like her SS - will become her required copay or SOC (share of cost) paid to the NH each mo,

Lucky she has an apt. Dealing with a house when they move into LTC has its own hot mess of problems....

you're mpoa. So is there a dpoa?

I know this is a lot to digest. I’d bet that her situation has been a crisis in the making. Her hospitalization was the tipping point. She cannot go back to her apt. She has cancer diabetes obesity. Cannot walk more than a few feet. She needs to be in LTC. It’s a hard reality to adjust too for her, you and others in her life. She does not necessarily need to stay at this rehab NH. She can move to another facility if they can provide the level of care needed and will take her Medicaid Pending / Medicaid Not all places can do chemo TX and followup. It may we’ll be that once she’s cancer stabilized, this place will want her moved to a traditional NH.

Ask her friends to help out. Like someone goes to her apt and gets all her winter clothes and launderers. Someone else does summer stuff. Another empties out a chest of drawers and brings to the NH. Your gonna have your hands & mind full with paperwork.

Again imo forget Horizon and instead spend your time & energy to get her to become a LTC resident in a NH as a “dual”. Between the M&Ms all care will paid for. There will likely be the eventuality that she hoes onto hospice. So be prepared for that. Good luck.
Helpful Answer (4)
rovana Aug 2018
Thanks - a great answer - really clear.
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Is the BCBS a supplemental? If they are my understanding is that Medicare runs the show.

If it is a Medicare advantage plan they are it. Those plans actually replace Medicare.

Make them give you a safe release plan. By law they can not release a vulnerable senior without one in place.

Best luck battling this decision. Ticks me off that they are so worried about their assets and not individuals.

Stick to your guns with this. Let me know about that plan please.

Hugs for helping your friend!
Helpful Answer (2)
mscherbina Aug 2018
Yes, it is a Horizon BC/BS managed Medicare plan.
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