Are you aware that Medicare pays for patient 80/20 as long as he is still sustaining vs progressing in Nursing Home? - AgingCare.com

Are you aware that Medicare pays for patient 80/20 as long as he is still sustaining vs progressing in Nursing Home?

Follow
Share

Currently, father-in-law is in Rehab Center under 20%pay, Medicare pay 80%. We received notice that he goes on full pay in three days because he is not progressing. There was a legal action taken in December which the patient only had to be sustaining with the help being given in the Nursing Home.

Is this a way that Nursing Homes make money considering full pay is more than what Medicare pays?

This question has been closed for answers. Ask a New Question.
21

Answers

Show:
1 3
In order to qualify for Medicaid, 2 physicians need to certify that FIL has 6 months or less to live. That may be the reason that your FIL's doctor will not certify him.

With Medicaid, each state uses a formula to calculate the spouse's share of the couple's resources called the protected resource amount PRA.
Helpful Answer (0)
Report

To: igloo572 If dementia is considered a terminal disease, then why aren't doctors approving hospice for FIL? He not only has RA but a heart and lung issue along with the dementia. Yet not one medical professional either at the NH or the hospital he was in before going to the NH would write an assessment that he was incapable of making his own decisions. His diagnosis from one geriatric psychologist in the hospital is that he can make simple decisions but not complex decisions. Crazy as this sounds, the NH claims they have seen a decline in his cognitive behaviour too but the therapist is not willing/qualified? to make a medical psychological evaluation. She states that he has reached a plateau.

JIMMO CASE - If he starts to fail when he arrives home, can he go back to Rehab to help him regain what he lost after being taken off of Rehab? When at home, he refuses rehab. He has no clue what this means financially. Once again; therefore, no hospice and no authority for Medical Power of Atty, which is all my husband needs. But it reads only if subject is deemed incapable.
I will let you know as much as I am informed about. I say that only because there will be a lot of information dropping to all parties and I just not be one of those due to my assistance being needed in other areas. THANKS TO YOU ALL!


Currently FIL is scheduled to return home. To: rucabe Our local Medicaid Office is being contacted today. Thanks. An attempt is being made to get as close to in home 24-hour care as possible which NH is in agreement with. Spouse has inheritance which hopefully will remain for her use. Custodial care is all that she needs right now.
Helpful Answer (0)
Report

I've been mulling Jimmo aka "Therapy Plateau" over and I bet that one of the consequences in changing the criteria from "progressing" to "reasonableness" is going to be that those elderly with advanced dementia may find that they are now not going to get the first month rehab done which was always done and Medicare has always paid for. Likely big bad news for the elderly & their family

I wouldn't be surprised if the view will be that the advanced dementia patient "reasonably" cannot benefit from therapy from the get-go as dementia is considered a terminal disease. If this happens, there will be a lot more elderly going onto hospice (the other big Medicare paid for benefit) upon admission. Now Medicare hospice does not pay for their room & board at the facility (like it does for the Medicare covered rehab period), so the R & B will either be private pay or Medicaid. But for the NH, more hospice is a total win as it brings in additional skilled care for their residents but doesn't cost the NH anything in personnel, equipment, etc as Medicare pays for all that to the independent hospice provider

It's quite quite different from continuing therapy for someone with a chronic disease like MS, CP, Parkinson's, secondary polio affects who has hit a plateau either in their ability or coverage. In my reading of Jimmo, the heart of what was in the case was about those chronic diseases. I could be wrong but I bet this happens

Olivia - would you let us know what happens for your FIL and what the doc's & the PT/OT say? We all learn from each other, thanks oodles!
Helpful Answer (0)
Report

OliviaC, Medicaid will cover custodial care of the eligible spouse,even if the other non Medicaid is still at home but can't care for him. They will, however, limit their activities to the care of the Medicaid spouse. But look into whether the other spouse is eligible for Medicaid in her own right. I would assume that if one spouse has met Medicaid's income eligibility standards, the other spouse is in the same financial circumstances. And, if the other spouse is infirm, why wouldn't you be seeking Medicaid assistance for her as well? Please check this out with a social worker and/or your local Medicaid office.
Helpful Answer (1)
Report

To loridtabbykat and rucabe We will be checking into this. Thank you for your prompts. At this point I believe Medicare paid for the County nurse who stopped by to see both parents before the FIL fell, ending up in NH. loridtabbykat - interesting point. If one spouse goes on medicaid when in NH, and then comes home, would medicaid pay for custodial care for him even though wife, not on medicaid, is still there. She has dementia and inactive so cannot care for him.
Helpful Answer (0)
Report

To loritabbykat: Medicare will not pay for "custodial care"' meaning cleaning, household chores and such. Medicare only pays for necessary medical care. However, Medicaid does provide aides to help with meal preparation, grocery shopping, laundry,etc, So if the patient qualifies for Medicaid (an income based bpublic assistance program) you can get assistance with custodial care.
Helpful Answer (0)
Report

If you read the terms of the Jimmo settlement, available on the link provided earlier by another poster, you'll see that the standard for continued care is whether continued care is necessary to maintain the patient's condition and prevent deterioration or backsliding. That is the new standard for reasonableness and medically necessary, and health care providers, who are still unfamiliar with the Jimmo case (as were two of our doctors) should be unformed of this so they can make the proper findings to support an application for continued care.
Helpful Answer (0)
Report

Pstegman- seriously? Only 20 days down from 100??
Helpful Answer (0)
Report

It may be too late for Olivia's FIL, but I urge everyone to get Long Term Care insurance. The younger and healthier you are, the cheaper the payments. Most policies cover custodial care at home or in assisted living or a skilled nursing facility.
Helpful Answer (2)
Report

So medicare will not pay for a Certified Nurse Assistant to come into the home to help with chores or pets or meals?
Helpful Answer (0)
Report

1 3
This question has been closed for answers. Ask a New Question.
Related
Questions