Cuts to Medicaid May Limit Access to Nursing Homes

[pnwmom]

19. Your aunt was misled. I'm so sorry. This shouldn't still be happening YEARS after the new regs were

put into place.

About 18 months ago I had to fight with my mother's nursing home to allow her to stay beyond the 21 days. They were holding on to the old standard, that said a patient had to be IMPROVING -- and in their opinion, she had "plateaued." The current standard is that if daily rehab is needed to MAINTAIN health status (not deteriorate) then Medicare would pay for up to 100 days (with a co-pay after 20 days.)

So I faxed them a letter along with the Federal regulations and they finally caved. (The new regs are often to their benefit, too -- since the reimbursement for Medicare is higher than for Medicaid.) Two months later, when Mom WALKED out of the nursing home (she was still in a wheel chair at 30 days), the staff stood by the door and clapped for her!

https://www.elderlawanswers.com/medicares-limited-nursing-home-coverage-12131

Nursing homes often terminate Medicare coverage for SNF care before they should. Two misunderstandings most often result in inappropriate denial of Medicare coverage to SNF patients. First, many nursing homes assume in error that if a patient has stopped making progress towards recovery then Medicare coverage should end. In fact, if the patient needs continued skilled care simply to maintain his or her status (or to slow deterioration) then the care should be provided and is covered by Medicare.

Second, nursing homes may wrongly believe that care requiring only supervision (rather than direct administration) by a skilled nurse is excluded from Medicare's SNF benefit. In fact, patients often receive an array of treatments that don't need to be carried out by a skilled nurse but that may, in combination, require skilled supervision. In these instances, if the potential for adverse interactions among multiple treatments requires that a skilled nurse monitor the patient's care and status, then Medicare will continue to provide coverage.

When a patient leaves a hospital and moves to a nursing home that provides Medicare coverage, the nursing home must give the patient written notice of whether the nursing home believes that the patient requires a skilled level of care and thus merits Medicare coverage. Even in cases where the SNF initially treats the patient as a Medicare recipient, after two or more weeks, often, the SNF will determine that the patient no longer needs a skilled level of care and will issue a "Notice of Non-Coverage" terminating the Medicare coverage.

Whether the non-coverage determination is made on entering the SNF or after a period of treatment, the notice asks whether the patient would like the nursing home bill to be submitted to Medicare despite the nursing home's assessment of his or her care needs. The patient (or his or her representative) should always ask for the bill to be submitted. This requires the nursing home to submit the patient's medical records for review to the fiscal intermediary, an insurance company hired by Medicare, which reviews the facilities determination.

SNIP