My Mom has Medicare A & B, plus Long Term care Insurance she has paid into 25 years. The nursing home just called and said she is no longer considered skilled care after rehab for 22 days and will have to go private pay; they had initially said Medicare would pay up until 100 days. So they are pushing me to make a decision about her nursing home care and say I have to appeal the decision to not be skilled and I have to make this decision within a few days. I am worried that they might just be after our money.

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This is the time to talk with a geriatric care manager and an elder law attorney in your state.

Nursing homes are often reluctant to keep billing Medicare, because they think Medicare coverage depends on the beneficiary’s restoration potential; but the standard is whether skilled care is required.

Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities. The nursing home patient who needs these skilled services should still be covered by Medicare.

The February 16, 2017 statement by Centers for Medicare & Medicaid Services (CMS) says: "Skilled nursing services would be covered where such skilled nursing services are necessary to maintain the patient's current condition or prevent or slow further deterioration so long as the beneficiary requires skilled care for the services to be safely and effectively provided."

Medicare has posted plenty of material for you to read.

But the most efficient way to learn whether your mom needs skilled care is to talk with an advocate in your state who can give you an objective view. It's important to coordinate Medicare eligibility with other resources like LTC Insurance.
Helpful Answer (3)

So here's the thing;

Medicare will pay 80% of days 21-100 IF (and only if) mom is progressing in therapy.

If she is not, and she cannot be discharged home or to Assisted Living, then they (or you) are looking to shift her to Long Term Care.

Does the NH know that she has LTC insurance? YOu want to sit down with the business office AND the SW at the NH/Rehab and hash this payment issue out.
Helpful Answer (5)

I am assuming that your Mom was in the hospital and was transferred to the nursing home for skilled care/rehab with physical therapy and occupational therapy. As Barb stated, Medicare will pay 80% of days 21-100 IF (and only if) mom is progressing in therapy.

If your Mom is not progressing in therapy (i.e. she cannot walk a greater distance today than she did yesterday or she cannot perform her own ADLs more independently than yesterday) or if your Mom refuses to participate in therapy for 3 days, then therapy is discontinued and her status changes from skilled care to long term care if she is unable to go home or to Assisted Living.

If I read your profile answers correctly, you and your Mom were living together. Do you want your Mom to return home or do you want her to go to an Assisted Living facility (many ALs calculates monthly fees based on a points system according to how much help your Mom needs).

If your Mom needs someone to help her bath, get dressed, take her to the toilet, supervising her as she walks with a cane or walker or if she uses a wheelchair, then a long term care facility might be a better fit for her.

You need to look at the long term care insurance policy and see what it pays for and how long it pays (most pay for 1825 days or 5 years.) Does it pay for Assisted Living facilities (rare) or just Long Term Care/nursing home facilities? If the insurance only pays for LTC/nursing home facility care, and your Mom needs physical assistance with her ADLs every day, then your Mom would probably be better off in the long term care facility.

If your Mom becomes a resident of the long term care/nursing home, you need to sit down with the LTC facility's Social Services Dept. and Business Office to determine how much the Long Term Care Insurance will pay every month and how much you are going to have to pay every month.

Then you need to contact the Long Term Care Insurance Company and tell them that your Mom is in _______ facility and that you want to activate her long Term Care Insurance Policy. {Who is your Mom's Financial POA and her POA-HealthCare--I assume that it is you.} It will take about 3-4 months before the insurance payments are sent to your Mom (or you if you are POA) and the "deductible period" has been met which means that your Mom needs to have been at the nursing home for 90 days or so before the insurance will begin paying for your Mom's care. Since your Mom has only been in the facility for 22 days, then she will have to private pay for her care (approximately 70+ days) until she meets the LTC Insurance requirements for number of days in the facility (90-120 days)

LTC Insurance pays for the PREVIOUS MONTH'S expenses. So at first, you will have to pay for approximately 3-5 months of care. {I had to pay $10,000+ for 2-3+ months as my Mom had met the 90 day qualification when her LTC Insurance was activated.} When the LTC Insurance checks come, either your Mom or her POA will have to sign them and deposit them into her checking account.

I am not sure about the payment situation for Assisted Living as my Mom went from home to the hospital to the nursing home. Maybe someone else could answer any questions that you have if you are planning to move your Mom to Assisted Living instead of having her stay at the LTC/nursing home facility.

In the LTC/nursing home facility:
Every 3 months, an Resident Assessment (required by Medicare and Medicaid for all M / M certified nursing homes) and a Care Plan will be completed by Social Service, Nursing, Dietary, Activities and Therapy (if your Mom had any).
Then there should be a Care Plan Meeting that your Mom and any of her family members or her POA can attend and are often encouraged to attend.

Based on the amount of help that your Mom needs with her ADLs, supervision needed due to behaviors, medications and treatments; your Mom will be assigned a Care Level. The cost of your Mom's care will be based on which Care Level she is given. Each state has a different formula for calculating Care Levels and how much each level cost.

Is that clear as MUD?!? C:--)
Helpful Answer (5)

She and you are very fortunate to have the long term care. I would think you should start that. The beginning is a pain as it can take a few months to start after you begin the process. Then long term can re evaluate every 6 months as though our parent has suddenly grown young. Be sure to ask a facility how they handle this process. The ADL s are different in states and medication is never one of them. The right place should work with you. We pay each month and then submit to the long term. It will run out if she lives on and on. Then as is frequently mentioned here her assets must go for care until she is near penniless.
Helpful Answer (4)

Wow DeeAnna, yes actually, your post was clear to me! Thank you for sharing your knowledge so succinctly & also making it easy to understand.
Helpful Answer (2)

Thank you to everyone that replied regarding my Mom and the nursing home. I now have enough detailed information to make an informed decision. I did appeal the decision as of this morning with Medicare so hoping that will keep Mom in skilled care longer as she needs to keep moving. I am her durable POA and I did live with her eight years until this last hospitalization. Thanks again to everyone and I pray she does well there or I will have to get her back home somehow.
Helpful Answer (2)

NH may and probably will bill for what Medicare does not pay unless she has supplemental insurance to cover the cost. If not she is looking at probably $2000+ in costs.
Helpful Answer (1)

If she has LTC ins as my husband has who has alz. He is using it now. I really didn't know or understand all rules of getting its benefits. First talk, if you can to person in company that sold it. Read it many times & write down questions. Write questions to company as they'll keep it. Saved me 2 months of his 90 days to qualify. In his case said had to be in licensed facility. Didn't say how many hrs. Found a place who kept him 1 hr a day for 90 days i paid for so then they started pay. We had alternate care on ours which gives more choices. One gal sent her hubby to adult day care for 90 days & saved her a lot of $ as it did us. Also ck on respite care. I'm sure I called the LTC company 20 times to get an understanding & wrote about each call. Date & person spoke to. They have been great mostly explaining. They also have made several reimbursement mistakes so keep on top of numbers. Didn't know I needed to be a CPA but good luck. Get info before you need it if possible.
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