Will Medicare (Part B) withdraw moms coverage in nursing home if we try to pay for difference of private room out of pocket? - AgingCare.com

Will Medicare (Part B) withdraw moms coverage in nursing home if we try to pay for difference of private room out of pocket?

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While my care giving is nothing compared to most posters on this forum, it’s a health care issue with my mom, and that makes it very important to me.

My mother recently had knee replacement surgery and was transferred from the hospital to a rehab facility that operates within a nursing home. Mom’s Medicare will pay for ten days of physical therapy in a semi private room.

Mom has done wonderfully, physically and mentally, since her surgery. Other than the fact that she can’t walk at this time, you’d never know she’s had surgery. Her physical therapists at the hospital said she’s going great.

All that changed today when she was transferred to the nursing home. I am one of her four daughter’s and dad is still alive, so we’ve been with her every day.

After everyone left the nursing home, it wasn’t very long until my and my sister’s phones started ringing off the hook. Mom is sharing a room with is much older woman that has far more troubles. The first call was to report that her roommate had messed herself and after an hour and several calls to the nursing desk by my Mom, no one had come to change the woman. Once the woman was changed, some soiled items were tossed in the trash can in the room. After several calls, someone finally came and took away the trash.

It was soon after the first round of calls that we started getting tearful calls to come and get her. My sister, who was a LPN, has tried to call the nurses station several times, thinking maybe she hadn’t received her meds, or a minute or two visit was in order to calm her, but there is no answer. The tearful calls have continued.

This behavior is totally out of character for my mom and we are worried. We believe she might see her roommate as a victim and/or Mom’s very scared. As stated, she’s a otherwise healthy 70 year old woman who’s been placed in a full blown geriatric ward (women rocking dolls, men and women walking the halls in hospital gowns with their bum showing, etc.) but you have to take what Medicare will give you.

We don’t know exactly how much Medicare is paying for her stay in the nursing home, but we were wondering if it might help if we could get her in a private room and pay for the difference that Medicare will not cover.

A friend mentioned that if we get her in a private room, Medicare might withdrawal coverage/payment if funds are being paid by the family for a private room. We don’t have a lot of money, but if it helps mom’s recovery we’ll find the money.

Can someone please provide insight on how Medicare (Part B) would work in this situation. Mom really needs the physically therapy that we can't provide and bringing her home at this time would only prolong her recovery. Thank you.

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This is a difficult question to answer because the type of insurance the beneficiary has is unknown. If the individual has an MAPD or Med Supplement health plan, they should call the health plan’s member service department to inquire how the insurance company would bill for the Medicare allowed amount (semi-private room) versus a private room. This is a question the nursing home should be able to facilitate based on the type of insurance the beneficiary has.

If the beneficiary has Original Medicare, they can call 1-800-MEDICARE to find out how Medicare would bill for the non-Medicare covered private room. Medicare Part A is "Hospital Insurance” which helps cover inpatient care in hospitals and skilled nursing facilities. Medicare Part B covers Medical and other services such as physician services.

Original Medicare Benefit:
Days 1–20: $0 each day.
Days 21–100: up to $144.50 each day.
Beyond 100 days: all costs.
There’s a limit of 100 days of Medicare Part A SNF coverage in each benefit period.

The beneficiary may also be expressing a concerned regarding a quality of care issue with the nursing home. Has the family talked to the nursing home about moving their mother to another room or a different area of the nursing home? The patient has resident rights under Medicare: including the right to be treated with dignity and respect; being informed in writing about services and fees before entering the nursing home.
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