What number of days Medicare and Medicaid pay for nursing home care? - AgingCare.com

What number of days Medicare and Medicaid pay for nursing home care?

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My mother recently passed away and I’m very concerned about the way the nursing home treated her. My mother had stage 4 esophageal cancer, and was getting chemotherapy for 3 years. In late November, she fell and had hip fracture surgery.

She entered a skilled nursing facility to get physical therapy for her leg. During the first month, she was making great progress in terms of mobility and being able to walk.

However, during her second month at the nursing home, her health started to decline probably as a result of her cancer.

Specifically, she would have diarrhea for around 3 days in a row and be okay for 2 days, she would then have diarrhea again for about 3 days in a row and be okay for around 2 days, etc. Also, about once a week she would vomit a few times a day.

Throughout her second month at the nursing home, this pattern continued. They did blood tests on two occasions during this period but other than discovering that she had a urinary tract infection, they could not find any reason why she was having persistent diarrhea.

Since my mother had already lost 25 pounds as a result of the 3 years of chemo and was not eating much, she was already very weak and the persistent diarrhea made her much weaker. It also made it difficult for her to do any physical therapy on a number of days during her last 2 weeks at the nursing home.

A few days prior to her 60th day in the nursing home, the nursing home staff told my mother that she could not stay there beyond 60 days, and that if she did stay beyond 60 days, she would have to pay out of her pocket since her insurance wouldn’t cover any stay beyond 60 days. They had my mother sign a document stating that she understands that if she stays beyond 60 days, she would be responsible for the bills.

My mother has Medicare and Medicaid (called Medi-Cal in California). My understanding is that Medicare pays for a patient’s stay in a nursing home for 100 days. Beyond that, I believe Medicaid (Medi-Cal) will cover the costs. Therefore, I don’t think my mother should have been held responsible for the bills if she had stayed beyond 60 days.

My mother left the nursing home on the 60th day even though on that day as well as her last 3 days at the nursing home she was extremely weak from the persistent diarrhea over the last month, and she could barely get out of bed. However, she decided to leave since she was afraid she would have to pay out of pocket if she stayed any longer at the nursing home.

When she came home, she could not go up one flight of stairs and I had to call the fire department to help her. During the night, her diarrhea would not stop and she was so weak she could not get out of bed. I finally had to take her to the emergency room the next day.

The hospital kept her for 2 days until her diarrhea stopped and then they discharged her to a new nursing home.

About a week later, she started vomiting uncontrollably the whole day and she entered the hospital again and was diagnosed with a kidney infection and lung infection. She passed away at the hospital.

I’m really upset at the way the nursing home sent my mother home even though she was very weak and ill, claiming that she would have to pay out of pocket if she stayed over 60 days.

Can I file a complaint against the nursing home? If so, with whom and where does the complaint need to get filed?

I would greatly appreciate any assistance you could provide to me. Thank you very much for your kind help. Tom

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VegasLady - the Medicare rehab situation has dramatically changed due to:
Jimmo vs. Sebelius Settlement--info can be found at this link
http://www.medicareadvocacy.org/medicare-info/improvement-standard/
thanks to BKW300 who posted on this a couple of months ago.

It's also know as the Vermont Therapy Plateau case. Really a game changer. Personally I don't think it will help most NH residents get care, actually I think it may provide for less care. But for those living in the community - like my cousin in his late 60's who has latent polio - this is good news as he can get PT, OT beyond the old # of set days. There was a whole series of posts on it, see OliviaC on 2/2/14. Jimmo is brand spanking new regulations to wade through.
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Even the hundred days was only covered in full if the person made progress in therapy. They could send you a "cut letter" earlier if not. And the days could start over only if the person was hospitalized 3 days or I think if they had certain surgeries or other medical occurrences. I think it is Medicare rather than Medicaid; Medicaid will pay for long-term care as well as post-acute/sub-acute rehab.

Here is what I think is a a current reference: www.medicare.gov/coverage/skilled-nursing-facility-care.html. It indicates that days 21-100 you pay a "coinsurance" of $152.00 per day which may be nearly the whole cost, after day 100 it is everything.
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Did you mean Medicare will now only pay for 20 days?
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It got worse on 1/1/14, Medicaid only covers 20 days. The Nursing home's hands are tied by the regulations. However, Hospice should have been in the picture, and Hospice is ordered by her MD. Was Hospice ever discussed?
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