Need advice, boyfriend received notice of Medicare non-coverage after today and nursing home rehab is not complete. Suggestions?

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Need advice, boyfriend received notice of Medicare non-coverage after today and nursing home rehab is not complete. Suggestions?

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Hello. Need advice. My boyfriend is 53 and he had his leg amputated on May 14th. He was transferred to Skilled Nursing on May 24th. He has still got his stitches in, waiting to see the surgeon, on pain meds, doing PT and OT, however they presented him with the Medicare non-coverage letter after today. He's was told it would take he would be in there 10 weeks possibly, and I'm wondering why they didn't tell him this sooner, they said he could have appeal, and he has, he has not gotten his prosthetic yet all he has done is been able to stand a couple times with assistance. He lives with his daughter who works and he has been practicing going down the hall with the wheelchair. He has been able to transfer from bed to chair and sometimes chair to bed. Do you see this as them justifying he's ready for outpatient treatment? or in home? Just based off this has anyone else been sent home that soon? He was on IV antibiotics until till 4 days ago. Thank you so much.

Medicare Paying for Care Rehabilitation Center Skilled Nursing Facility

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Medicare is required to give a 3 day notice of discharge. Here is how Medicare works: Medicare will cover up to 100 days at a skilled nursing facility. The first 20 days are covered at 100%; days 21 to 100 are covered at 80 percent. Coverage is based on a skilled need: PT skilling for OT and speech therapy meaning that a need for OT or speech alone does not indicate a skilled need, IV antibiotics, new feeding tube, certain wound issues. The key to coverage under the therapies is that there must be progress towards a goal. If the goal is achieved or the person plateaus ( meaning that the person has reached their maximum level of functioning). A subscriber has the right to appeal a unfavorable determination. Yes, people have been sent home. The 100 days are not an entitlement nor guaranteed. Does he have Medicaid coverage as a supplement to Medicare? If not, he should apply. I would speak with the social worker or case manager at the facility. There also should be a discharge planning meeting as well as a written discharge plan. Good luck.

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Thank you so much for your information, it is big help. 🙂

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https://medicareadvocacy.org/take-action/self-help-packets-for-medicare-appeals/

Improvement Standard, that is the name of your issue. Traditional Medicare covers up to a 100 days of in-patient rehab services. 20 days at 80% and the 80 days at 50%. However, the patient needs to participate in therapy and show improvement.

He can appeal. However, failure of the appeal means that he would need to pay the facility. If he has that kind of resources to take on that financial risk, then you should ask the facility for an estimate for private pay now. They may have a better rate if he pays direct and they don't submit to insurance.

In appeal, he would be arguing that he is continuing to improve and therefore Medicare should continue to grant coverage. Typically a lawyer won't have much value to add. You can read more about this issue at the Center for Medicare Advocacy, medicareadvocacy.org.

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Thank you for your information this is a huge help. 🙂

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Imho, you should speak to the Ombudsman. This man was very similar to a patient who was in the Nursing Home at the same time as my late mother. He, too, was 53 years of age and was a recent amputee of his leg. He confided in me that the Nursing Home was pushing him to get out and he hadn't even received his prosthetic limb! You MUST advocate for your boyfriend.

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It takes months to get a prosthetic limb. We all understand that right? It’s not realist to stay in rehab for months if you can’t afford it.

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Contact your local nursing home ombudsman; he may be able to help. Medicare has recently decreased the number of PT hours. But if he's only been there about 16 days, that doesn't sound reasonable.

In California, the law requires a skilled nursing facility to provide a patient with a 30-day notice to vacate and even then, there must be a safe place to go to - assuming he is still qualified. Make sure you have a medical assessment. If he's already appealed, Livanta, the agency who handles the appeals, is supposed to give him an answer I believe within 48 hours. What was their decision?

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They decided to allow a 2 week extension. He had to drop Humana and has Medicaid and medicare. The goals are to work on bathroom on his own and hopping with more pt goals.

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They have criteria for what constitutes the need for rehab. Once you reach that stage, Medicare wants you out of there. I have seen this twice. Once with a friend’s Mom and then with my aunt. You can appeal but be prepared to hear their negative answer. Your boyfriend has reached his rehab threshold and they want him out of there like yesterday. Have you spoken with his doctor??

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talk with your doctor about the situation so you can have the necessary medical info. talk with your local dept. of Aging - the folks there should also be able to give you some guidance, The staff where he is should be able to give you info about organizations that provide in home therapy to see if he is eligible. If qualified, these services would be paid for by Medicare. Does he have any other medical insurance - if so talk with them. As mentioned by others, he may be eligible for Medicaid.

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I haven't been able to find any good articles (and the Medicare site doesn't provide a lot either), but I do recall warnings in the news about cut-backs for inpatient rehab. It had many SNFs and PTs very upset and resulted in many PTs either losing their jobs or being reduced to a pittance for hours (often resulting in no health insurance and resorting to working for multiple SNFs, which during this pandemic leads to spreading the virus!)

I do know there are certain criteria that need to be met, and once they are met, Medicare will discontinue coverage. It is likely that being able to transfer and "get around", however minimal that might be, along with less or no need for specialized nursing care (IV antibiotics, wound care, etc) were the deciding factors.

That said, the Medicare website DOES state this:
"Physical therapy
Medicare Part B (Medical Insurance) helps pay for medically necessary outpatient physical therapy.

Your costs in Original Medicare
You pay 20% of the Medicare-approved amount, and the Part B deductible applies.

Note
Medicare law no longer limits how much it pays for your medically necessary outpatient therapy services in one calendar year."

So, he should be able, through his doctor, to arrange PT at home and/or once he is more mobile, at an outpatient facility. He might also qualify for help with medical equipment that will help him at home.

I haven't had to do rehab, but I was on IV antibiotics as well as TPN (intravenous feeding.) I HATED being in the hospital and pushed enough that they finally sent me home after almost 4 weeks with home nursing coming in to set up the feed bag, clean and change the dressing around the IV port and draw blood to test for adjustments to the antibiotics. Supplies (antibiotics, TPN and various items like gloves, cleaners, etc) were delivered on a regular basis. There were 2 different ones, both multiple times/day and I was provided with the antibiotics and a pump, which I was able to do myself. At the time I was not on Medicare, but it should be similar.

Best of luck to BF! May he work hard and get back to as normal as possible soon!

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Thank you for all the information 🙂

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I am a bilateral amputee, as well as 8 fingers amputated. I was deathly ill prior to the amputations (septic shock). PT/OT included two weeks of training to do the transfers you mentioned. There was no standing, obviously. Then I went home,

What you are describing is normal. I know it is scary, but it is normal. He can continue to heal at home. Once his stitches are out, he will work with his prosthetist at an office. PT appointments can begin to practice walking. I also practiced falling - to learn how to get up.

I read through all the other comments. They are trying to be helpful, of course. However, unless one has actually been through this, one can't know. The hardest part may be that going home is very scary. Again, quite normal.

There are several amputee sites on Facebook. Reach out to one or more.

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Hi, thank you so much. I really needed to also hear from another amputee along with the others as well. I need to ask him if they have done fall prevention etc.. he is a 400 pound guy and is losing weight but still everything will be twice as hard. His daughter gets all the medical from the doctor etc.

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Medicare used to pay for 30 days of medically necessary rehab if patient was co-operating and showing progress. After that time the patient could appeal discharge, but most of the time the appeal is denied and the patient must pay for continued rehab or for whatever help is needed for in home care once he or she is at home.

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You can contest Medicare decisions. The skilled nursing facility is SUPPOSED to have a social worker. He may become eligible for MEDICAID but do not get married since marriage becomes joint income. Medicare only covers up to 100 days after hospitalization, which is ample time for most, and there must be documented IMPROVEMENT. If your boyfriend is not improving or is not trying hard enough they WILL reject him--wilful not trying means the burden will fall on him or his loved ones. If the therapist charts "REFUSED" that is a red flag for Medicare.

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He got lucky, was ready to go but last minute the third appeal worked. He had to drop one of his 3 coverages and between the other, it allowed the additional time. Not sure exactly how that works. Thank you for your assistance. 🙂

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"...he has not gotten his prosthetic yet all he has done is been able to stand a couple times with assistance..." IMO, in 3 weeks he hasn't made enough progress and his expectations don't seem realistic. Amputation, rehabilitation and a prosthesis are a process.

Why was his leg amputated? Was it a scheduled or traumatic amputation?

How much does he weigh?

There is a whole bunch of pre-prosthetic training to prepare the residual limb for a prosthetic. He can't be fitted for a prosthetic until his wound heals and his socket is built. Where is he in the process? That he's in a wheelchair "practicing going down the hall" suggests to me that something is not progressing the way it should.

There are certified peer mentors who offer valuable support to people with amputations.

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He weighs 400, he's dropped 30 just in the last month being in the hospital then NH. I just got added to his HIPAA so I am speaking to the doctor shortly.

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Usually in-facility care is determined by need for care from medical staff: IVs, complicated infections, complicated dressing changes... He appears to not need an IV any more and has progressed to the point where he can get around in a wheelchair. Congratulations! Appears that Medicare's criteria for in-facility care are not met with his progress. He will probably still need outpatient physical therapy and doctor visits. If finances are an issue, he should apply for Medicaid.

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Thank you..he ended up last minute being approved for another 2 weeks. He had to drop one of the 3 coverages (he can pick it back up when he leaves) I'm not sure how that works, but between the two. He's working on hopping, and began working going from wheelchair to a walker for the first time. I appreciate the assistance. 🙂

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Not to be blunt, but they always send people home too early. I would appeal and when the appeal is likely denied, then appeal again. Also, I would request a home visit by a physical therapist from the rehab to determine what skills your boyfriend might need in order to return home as well an any modifications the home will require (like grab bars, bath chair, bed rail, commode, removal of throw rugs, bathroom accessibility etc. If he is on Medicare, then he should qualify for at home nursing, physical therapy and occupational care. I wonder if rehab facilities are even more anxious to discharge patients in these days of Covid?? But discharging too soon can be very dangerous as he could fall and land back in the hospital with a broken bone or head trauma. The discharge process is a very delicate balance.

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100 days in patient rehab is sufficient time for most (providing they are trying), and things like grab bars are NOT covered by Medicare.

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Please confirm if he is dual eligible for Medicare and Medicaid. In this situation, it appears that Medicare has determined that his continued stay is not medically necessary. You can and should appeal - but with the IV antibiotics have been stopped and he may actually be ready for a lower level of care (even though you may disagree). If his daughter cannot care for him in her home, he may be able to go to another facility that would be covered by Medicaid. Medicaid covers custodial care. Please check to see if he has full Medicaid benefits. A social worker at the current nursing home can guide you.

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There is a third appeal in front of an administrative Judge.

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Based on the comments and your answers to them, it looks like he doesn't have original Medicare. It looks like he has a Medicare Advantage plan.

What that means is that Medicare isn't making the decisions, the insurance plan is. To see the difference between original Medicare and Medicare Advantage there is a 15 minute Medicare Class video (free) at http://MedicareQuick.com/Class that explains it pretty well.

Fortunately, there is an appeals process for Medicare Advantage Plans. Step one is to file an appeal with the insurance company. Make it an emergency appeal so they have to give an answer right away. Additionally, he can't be discharged while an appeal is in process.

There are several levels of appeals so be sure to continue to the next level if he is denied.

Also, ask about the Ombudsman program. This will vary by state, but it's an agency that deals with complaints against nursing home facilities.

And if he's on Medicaid, see if there is someone in that office that can assist. Additionally, if he is 100% full share of cost (meaning he doesn't pay anything) and your state allows it, he may want to dis-enroll from the Medicare Advantage Plan and go back to original Medicare, with Medicaid paying the co-pays and deductibles of Medicare. Obviously you'll want to talk with someone who knows the ins and outs of your state prior to doing this, because there is on limit on your potential costs with original Medicare.

Finally, if there is a Legal Aid in your town, or nearby, contact them to see if they can assist as well.

Hopefully, you'll get some relief. I'm sorry that the two of you are going through this.

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Medicare advantage plans limit rehab . Last year my dad and I were in post hospitalization rehab at a SNF after pneumonia. His plan limited his rehab to x3 per week. Original Medicare paid x5 per week for me. He was discharged to board and care At about 6 weeks. I was able to stay full 100 days.
You get what you pay for.

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Makmom, SSI in Supplimental income or actually Social Security Disability. Two different things. I will go with disability since he gets Medicare.

Chelly, seems he is on SS disability. As such, he receives Medicare and maybe Medicaid. Medicare determines how long you will be in rehab based on the reports that the Therapist sends them. All he can do is appeal the finding. There have been members who have been successful. Hopefully they will chime in.

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He’s 53, why is he on Medicare? The underlying issue concerning rehab, regardless of the public or private funding source, is whether he has reached “maximum medical recovery” in the setting he is in. Most policies have a maximum number of rehab days, but the patient will not get all of them if the facility determines that there is nothing further they can do for him in that setting. A case conference with the family is required at periodic intervals. If you attended one of these on the appointed day, the facility staff should have told you the reason if you were allowed to
participate.

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That I am not sure of. Thank you so much for the reply

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Is BF on Social Security Disability and Humana is his Medicaid insurance?
I am surprised that he is being released so early for an amputation. The PT alone should take more than the 20days Medicare pays 100% for. What is the reasoning they are giving for the discharge? Has he hit a plateau? Maybe the facility is not equipped to give him the full physical therapy he needs? My friend, who lost a leg, was in a specialized rehab. They actually had a car so he could learn how to get in and out of it.

I agree, call his surgeon and tell him what is going on.

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I don't believe it is Medicaid. He is 53. SSI for sure. I will double check though. He did say they told him he was doing very well, his words, which they could mean he hit the goals. Thank you so much for the info.

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Usually at this point folks are discharged to home for out patient PT. Often people leave the rehab centers without the prosthesis. It can take a while to make.
I don’t think it’s an unreasonable DC. They have to move him out due to insurance rules.
If he is able to do what you say it’s time for him to try outpatient PT. What else can they do? Now it’s up to the patient to do the work to get better.
If he can’t then maybe apply for community Medicaid for NH placement but from what you’ve said he is progressing nicely.

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Yes I agree, now that you say it this way, just wasn't sure not having the prosthetic. Thank you so much for the reply.

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Are you sure it’s a Medicare denial? I’m asking because of his age. Has he applied for Medicaid?

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Yes, I have a screenshot and it's definitely Medicare. He has Humana Gold.

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Thank you all.

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When Medicare says your time in a facility is up and your coverage is ending, most facilities can’t get you out fast enough. My husband could have used more time in physical a d occupational therapy as well, but he reached the end of his coverage and the rehabilitation facility said bye-bye.

Have him contact the social worker at the facility for help. Make sure that he and his daughter meet with the discharge planner to set up home health aides, nursing care and therapy. Medicare will pay for that.

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Thank you so much. I'm waiting to hear back from him and will pass this on. Kind regards.

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Do not let them discharge him. You and especially his daughter need to make it loud and clear it would be unsafe to send him home. There is no one to take care of him at home. Who was it that told him 10 weeks? The doctor needs to help with the appeal to Medicare if Dr. believes he needs more time there.

Need advice, boyfriend received notice of Medicare non-coverage after today and nursing home rehab is not complete. Suggestions?

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