Medicare Therapy Rules Made Easy
Most of us take for granted that we can get out of bed in the morning and do all the things necessary to head out and face our day. You know… the simple everyday things like moving around our house, showering, getting dressed and eating breakfast. I might be a little foggy most mornings but I don’t think about whether I’ll face an enormous challenge in measuring out the coffee or pouring the milk. The point is the routine is just that…routine.
But if your parent is frail, you know that there’s nothing routine about these activities — that for them, doing even the simplest things just can’t be taken for granted anymore.
The mobility and functioning that’s essential to independence and safety suddenly becomes a big effort. And, Daughterhood really happens when we have to get involved in helping our parents do the things that they can no longer do by themselves. This is when their lives and ours get hard.
That’s why, from a daughter’s perspective, you want to be super invested in anything that can help maintain or restore your parents’ ability to handle daily tasks independently and to get around on their own.
And the most useful tools in the independence toolbox for older adults are the three therapies:
physical, occupational, and speech/language. These therapies, working together, can help your parent continue doing all the usual things they normally do – or help them get back to doing these things after an accident or surgery.
Read: A Go-To Guide for Understanding Your Parents’ Rehabilitation
Unfortunately, the Medicare rules around how and where your parent can get therapy are incredibly COMPLICATED! As part of our series on therapy and functioning at home, I’m going to boil it down for you here.
The thing to remember is that Medicare pays for therapy through four main service pathways. Two of these pathways are for post-hospital care only and the other two are available regardless of whether your parent has recently been in a hospital.
Here’s how each pathway works.
Therapy in a Skilled Nursing Facility
What many people don’t realize is that most nursing homes do double duty as places where people live when they can’t take care of themselves anymore AND as facilities for short-term rehabilitation therapy following a hospitalization. These days, the majority of frail older adults who need intensive rehabilitation therapy after a hospital stay receive it in a nursing home – referred to as a “skilled nursing facility” – where they’ll stay for about three weeks before going home.
Medicare-covered skilled nursing facility care may provide any or all types of therapy as well as the nursing and other clinical care your parent might need before going home. It’s pretty typical for an older adult who has had knee or hip replacement, or is recovering from a hip fracture, to receive therapy in a skilled nursing facility following hospitalization.
Read: The 3 Surprising Medicare Benefits You MUST Know About
If your mom or dad spends more than three nights as an inpatient in a regular hospital, and has a need for skilled care, Medicare will cover 100% of the costs for the first 20 days of care in a skilled nursing facility. After 20 days, there’s a 20% copayment that can be covered by Medigap, Medicaid or out of pocket.
It’s important to note that Medicare pays skilled nursing facilities by the day, like a hotel, which means that most facilities aren’t in a big hurry to discharge your parent. And, the more therapy your parent gets, the more money per day the facility gets. I’ve had quite a few people tell me that they feel their parents are getting TOO much therapy and that’s entirely possible. Remember, it’s well within your rights to question how much is being provided.
Therapy in an Inpatient Rehabilitation Facility
In some cases, your parent may be discharged to something called an “inpatient rehabilitation facility” which – from a daughter’s perspective — could easily seem indistinguishable from a skilled nursing facility.
However, inpatient rehab is usually a more intense place than a skilled nursing facility. These facilities are licensed and paid as hospitals and can be great for a younger person who’s recovering from an automobile accident or a traumatic brain injury (think Gabby Giffords).
For the purposes of Medicare coverage rules, all of the normal hospital copayments and deductibles apply here. These facilities get paid a lump sum for the whole stay just like regular hospitals.. So, in contrast to the skilled nursing facilities, they’re going to be working a lot harder to discharge your parent quickly.
If you ask me whether your parent should be in an inpatient rehab facility or a skilled nursing facility, I’d have to honestly say that, for most frail older adults, a really good skilled nursing facility is a less expensive and more appropriate place for recovering from a hospital stay.
But, what makes all this even more complicated is that quality varies tremendously between and across both types of facilities. And, sadly, much of the time the hospital’s making a decision that has very little to do with what’s best for your mom or dad and everything to do with getting them out of their hair as quickly as possible.
Read: 5 Safety-First Strategies for Your Parent’s Hospital Discharge
Therapy from a Home Health Agency
At some point, either right after a hospitalization or after a stint in the skilled nursing facility, your mom or dad is going home…..still needing therapy and nursing care but too fragile to get out of the house easily. In this case, Medicare will pay for a limited amount of “home health” care, which is really mostly rehabilitation therapy at home.
I think one of the best things about “home health” care is the opportunity to have an occupational therapist on site helping your parent relearn how to interact with his or her home environment. Home health is not restricted to post-hospital care and is available anytime as long as your parent meets the fairly strict criteria for needing it.
To qualify for the benefit though, a doctor must certify your parent needs it… AND, that doctor must actually have seen your parent, in person, sometime within the last 90 days to verify the need for home health.
You can see the irony here… that your parent has to be so frail that it’s not reasonable to expect him or her to leave the house and yet, somehow has to get to the doctor to get certified for needing home health. Argh.
Watch: Daughterhood Voices – When Answers Are Hard to Find
But, once you get your parent certified, there are no copayments or deductibles. So that’s something!
Outpatient Therapy
If your parent has Medicare Part A (hospital) coverage, which most people have, or if your parent is enrolled in a Medicare Advantage plan, all of the three pathways mentioned above are available to you.
If your parent has Medicare Part B (or is enrolled in a Medicare Advantage health plan), he or she may also qualify for outpatient therapy services, which are very similar to the therapy you and I are familiar with – where you go to a therapy center and work with a therapist.
Because this is Part B, if your parent is traditional Medicare Part B (as opposed to a Medicare Advantage plan), there’s a 20 percent copayment and the Medicare Part B deductible applies. That’s pretty straightforward.
What’s not straightforward is that there are limits to how much therapy’s reimbursable under the Part B outpatient therapy benefit. Generally, your parent can get $1,960 worth of combined physical therapy and speech/language therapy and $1,960 worth of occupational therapy without any problems or questions. And if the therapist can substantiate an ongoing need, your parent may qualify for another $1,740 worth of therapy in each category through something called an “exceptions process.” But that’s not guaranteed.
Phew. Who thought this all up?
Therapy When Your Parent Lives in Assisted Living or a Nursing Home
Things can get pretty murky when your parent is living long-term in assisted living or a nursing home – in terms of the service category under which Medicare will pay for therapy. I’ve created the handy little table below – just so you know what’s what when your mom or dad lives somewhere other than a typical home.
Bottom line: This is a huge mess. Medicare is a conglomeration of benefits tacked on and revised piecemeal over time, with more of an eye towards cost control than what will work best for the families who have to navigate it. So, best of luck because you’ll need it and let me know your experiences in the comments section!
Hi, Anne,
Thank you so much for this incredibly helpful information … especially the parts about distinguishing between a “skilled nursing facility” and “inpatient rehab” and the “no copayments or deductibles” for home health care once your parent is certified. I have two questions for you:
1) Is there a way to find consumer ratings on skilled nursing facilities? I’ve had several friends whose parents were emergency hospitalized and part of their discharge plan was to go to a skilled nursing facility. It was troubling to them to get a list of possible facilities and have no information about the quality of care these facilities provide.
2) What if your parent’s doctor doesn’t think your parent qualifies to be “certified”? Is there a way to appeal this or would you just have to take your parent to another doctor for a 2nd opinion?
My sister is in a skilled nursing rehab after breaking her femur in two places. The dr doesn’t want them to step up the p t that would put any pressure on the leg by standing on it until March. She still needs therapy to move from bed to chair or toilet. Now they are telling her she has to move to another facility which she will have to pay for. How is that possible if she is crippled.
April,
You can go to the Center for Medicare and Medicaid services (https://www.cms.gov/) where you can find the latest survey ratings. Every facility goes through an annual review qualified by a star rating of 1 – 5. A rating of 5 from CMS is the highest rating a facility can receive. A rating below 1 results in the facility closing. A facility must be open for one year before it can receive a CMS rating. And until a CMS rating is received, the facility cannot get paid through insurance. For the first year a facility has only Medicare or private pay patients.
Use Google reviews to check on the different facilities you are considering as well.
I hope this helps,
Deb
My dad will be 98 in Sept. He was in an assisted living facility for 3 months, then had to go to hospital and is now in a rehab facility. If he he there 90 days and uses up his Medicate benefits, where can he go so I can get help paying for it. We cannot afford to pay for nursing home.
Hi Barb — Thanks for your question. I just saw it now and thought I’d respond right away. It’s a really good question and also important.
First, you might peruse the blogs that are categorized under the “paying for long-term care” category on the website. Especially look at the “Medicaid” blogs.
Second, talk to the assisted living facility about whether he can return after he’s discharged from the Medicare nursing facility short stay. It may be that they can manage him … I don’t know enough about his condition or the original facility to know.
As for paying for nursing home care…. this is where the Medicaid blog will be most useful to you. There is really only one program that helps with nursing home care and that’s Medicaid. Eligibility for this program is quite different than Medicare — there are quite a few requirements to gain access. But, it’s there to help. Otherwise, the only other option is to pay out-of-pocket, which is quite challenging for nearly everyone. This is a very big gap in our system of long-term care that few people realize exists until they come across it in their own lives. Good luck with it and thanks for reading the blogs and for reaching out.
Anne
You are a gift! Thank you for this info. I know it has helped me (for my mom) tremendously!
Cathy K.
my dad only has part A and a secondary that says it does provide him benefits for skilled nursing facilities and besides that the facility is out of network with that secondary anyway. So I understand part A will cover room board and General Nursing Care and Therapies but who will pay the doctor’s? Part B as I was told usually covers doctor charges at 80% leaving the patient responsible for the 20% coinsurance physician charges or it can be billed to the secondary but in his case a moot point.Doctor Who will see him at the facility is a doctor who works for and at that facility. So should we anticipate him receiving a bill dr charges? It’s very confusing because all these websites say Medicare pays the first 20 days at 100% but it doesn’t mention anything about the doctor charges.
Also when all these web sites say Medicare covers the first 20 days at 100% and none of them are specific to say part A covers 20 days at 100% for therapies General Nursing Care room and board however doctor’s charge be and if you don’t have it you’re responsible. So it’s really confusing it makes it seem Part B doesn’t matter as long as you have party you’re fine at the first 20 days and after that you’re only responsible for the Medicare A coinsurance of 16450 per day for 2017. So does that mean and skilled nursing facilities under part a that’s the only time party is paying for doctor visits? Sorry it’s so long but I tend to overthink and analyze things.
THIS WAS ALL VERY INFORMATIVE. i AM STILL CONFUSED. I AM GOING TO HAVE A KNEE REPLACEMENT IN A COUPLE OF WEEKS. i HAVE
MEDICARE A AND B AND KAISER SR. ADVANTAGE. I LIVE ALONE AND WILL PROBABLY NEED SOME CARE AFTER FOR A FEW DAYS.
sO, AM I TO UNDERSTAND I HAVE TO BE IN THE HOSPITAL AT LEAST 3 DAYS BEFORE I CAN QUALIFY TO GO TO A SNF? tHAT IS ALL BY THE
DOCTORS RECOMMENDATION OF COURSE. OR CAN I HAVE HOMEHEALTH CARE FOR PHYSICAL THERAPY UNTIL I CAN DRIVE OR FIND
PEOPLE TO TAKE ME TO THE FACILITY? I AM 70 YEARS OLD AND THIS IS MY 3RD SURGERY IN 1 AND HALF YEARS. MY BODY IS GETTING
WORN OUT AND I COULD SURE USE SOME HELP. CAN YOU TELL ME WHAT WOULD BE AVAILABLE TO ME? I CANT SEEM TO GET THE
RIGHT ANSWERS FROM KAISER OR MEDICARE. THANK YOU SO MUCH, A
Hi Anna — Kaiser Senior Advantage is a Medicare Advantage plan. The good news is that Medicare Advantage plans can waive the 3 day rule so that you can get rehabilitative care in a skilled nursing facility (SNF) without having a 3 day prior inpatient stay. You could also (with the doc’s referral) receive physical therapy at home under the home health benefit. The one caveat to all of this is that the health plan has to approve it which may require that your doctor haggle with them. Good luck!
SEE ABOVE COMMENT.
Hi Anna
I am 80 and scheduled to have a knee replacement on Dec. 6. I have the original medicare A and B. Since I live alone in an apartment, my doctor is sending me to a skilled nursing facility after one night stay in the hospital. He says that medicare will pay for it. Is this an exception for regular medicare also?
Nancy K
My mom was hospitalized and went to a rehabilitation center, she was there for three weeks, she became mentally and physically debilitated and we had a hospice eval, the only hospice the facility allowed us to access was owned by the facility, our family was distressed at the nurse and the encounter and recinded the hospice in less than 24 hours, we contacted another hospice and made arrangements to move her back to her assisted living with that hospice, the agency is now charging my moms estate room and board for four days, due to what they said was they had done no rehab on her in those four days, she was still given pain meds and was assisted in all other cares and had nursing supervision, also they were not notified of rescinding hospice, this happened over a weekend and the facility did not want to cooperate with the hospice Please let me know what i can do to resolve this issue
Pat, I’m so sorry you’re having to go through this. You should do the following:
1. Tell the organization (agency) that she’s going to: Call the Medicare Rights Center National Helpline, which is an organization that advocates and sometimes litigates on behalf of beneficiaries.https://www.medicarerights.org/programs/national-helpline.
2. Call your state long-term care ombudsman, which is hard to find but you can start at the http://www.n4a.org.
3. Also call your state “quality improvement organization” (QIO) which is part of the Centers for Medicare and Medicaid Services (CMS) and is charge of beneficiary complaints.http://www.qualitynet.org/dcs/ContentServer?cid=1228774346765&pagename=QnetPublic%2FPage%2FQnetTier4&c=Page.
4. Call these organizations – maybe starting with the QIO
I hope this helps ~ Anne
My Dad is 86 with Parkinson’s (w/no tremor) and a long history of Atrial Fib, by-pass surgery and controlled diabetes. On 7-15-19 he had a mild stroke and they discovered a 90% blockage, was Hospitalized 3.5 days, sent to SNF Rehab to await a stent, ended stay at SNF went directly back to hospital to get stent, and back to same SNF Rehab for two weeks and was released with Fidelity homecare PT/OT/SPEECH THERAPY. EXACTLY 20 days after leaving SNF my Dad fell and the Dr. at ER said it’s a fracture requiring Kyphoplasty. Being on Coumadin/loeri g INR for surgery plus a urine infection AND A HOLIDAY weekend, the procedure is scheduled for this TUES 8-3. Social worker told me he is not not covered and would have to make Co-pay of 146$ to go to SNF post his Kyphoplasty because “this fall was not 60 days from his last stay at SNF Rehab?? Isn’t he still within the 100 days for this benefit period? Hospital is recommending SNF and frankly they have his INR at very dangerous low level for my Dad, he is talking about things that aren’t there and didn’t know where he was a few times yesterday. Finally after speaking to floor Doc, they brought his INR back up with heparin… He is going to need rehabilitation after kyphoplasty and I am prepared to take care of him at home with homecare services like he had before but is this really true that SNF POST HOSPITAL RELEASE not Covered? And requires a co-pay? He has OH ANTHEM MediBlue Essential (HMO) W/DENT & VISN.
Hi Laurel – Medicare only covers SNF stays under the following conditions: that, within the last 30 days, the patient was in the hospital for 3 nights, admitted as a inpatient (not on observation status, not in the ER). The “benefit period” concept only applies to coverage for the hospitalization. However, here’s the catch: ALL of these rules can be waived by Anthem. That is, the private health insurance company through which your Dad is getting his Medicare coverage has the ability and authority to “waive the 3 day prior hospitalization” requirement. So, if you can, give the health plan a call and explain that, without SNF coverage, your father is at risk of more expensive and serious care needs and ask them to approve the SNF stay. I hope this helps!
My mom went into hospital March 10th and was d/c d on March 16th to rehab for 3 weeks . The rod that was inserted in hip has moved and they r going to replace hip now this week…what happens w rehab costs now?
Hi Anne, a friend of mine was in the hospital for 10 days and diagnosed with Dementia.She is 86 yrs.old,no family,I am her Power of Attorney,she has Medicare and Medicaid.,she lives in New Jersey and I live in California.I admitted her for Short Term Rehab in a Nursing Home but she is very frail and not responding to PT.,she is not communicating and she is due to be discharged by this week 4/28/18. She was admitted here on 3/16/18.They are looking to send her to another place as a long term resident.
I would like for her to stay where she is now because a friend of mine lives nearby and visits her DAILY and makes sure she is clean and eats a little bit.They tell me she will be in a waiting list for long term in this facility.
Is there anything I can do to fight this decision? I would prefer for her to stay in the same place.
Oh boy. This is a bummer. Unfortunately, there’s nothing you can do to force a nursing home to take you. They have a certain number of beds dedicated to “rehab” and they make considerably more money on these than on the beds dedicated to “long-term care.” Sounds like either the long-term care beds are taken and they’re not going to shift a rehab bed. Another thing to try is this site, http://www.nj.gov/ooie/contact.shtml. This office is called a long-term care ombudsman and is set up to help consumers!! Give them a call and just talk to them about it.
Hi Anne, My mother just had hip surgery and was sent to a SNF. She is asking us to take her out. The SNF has been really rude and has only worked her hands in therapy pushing a pedal round and round. Nothing for her legs. They want to just put a brief on her instead of getting her up on bedside toilet, She needed to go to bathroom and the nurse came in and said it was not her job. The next day she needed to go to bathroom, the cna came in and said she would have to wait because the other person was gone to lunch. (yet, 3 nurses at station) and an hour later mother had wet herself. Dr said she would be there about 2 weeks, the therapy person said no, 6 to 8 weeks. What they are doing, we could do at home with home health. Our question is if we take her home will she be able to get home health without penalty? the doctor said he would order it for her. We are confused. Please help! thanks barbara
My 85 year old mom started to have problems with her knee and couldn’t walk without lots of pain. She was walking a few weeks ago and now can only stand up to go to/from wheelchair.
After many doctor appointments we discovered she had two fractured vertebrae in her spine. We had to bring in 24 hour help to help her as she lives by herself. The cost adds up and we are paying out-of-pocket for now.
Now she’ll go through outpatient surgery to fix the vertebrae. The surgeon said they have to fix the back before fixing the knee. We’re not clear what we should ask for post-op from her health insurance. We think she should go short-term rehab and hopefully get strength back to walk again. It looks like the orthopedic doctor will have to make the case to Humana (she has PPO with their Medicare plan). Her primary care doctor thinks short-term rehab is a long shot as there wasn’t a fall or other trauma that created the situation (other than old age).
Any advice on options after the operation? After reading this post we’ll definitely look into getting Humana to either pay for short-term rehab or “home health care”. Any additional tips are appreciated!
Sad and glad to know I’m not the only one going thru all this. My 86 year old father had surgery On 7/17/18 to remove a tumor and replace the vertebrate in his neck it had broke as well as to relieve his spinal cord it was bending. He stayed in the hospital and was discharged on 7/27/18 to an acute rehabilitation hospital. Because of the spinal cord ingury he is very week. He was put on a feeding tube because after radiation and the surgery to remove the tumor his throat muscles are not working properly. He is weak and has hardly any core strength and very minimal leg movement. He has been in acute rehab and has made some progress but I guess not enough because today we are being to insurance is reviewing his case and has not approved his 2nd week stay yet. He is doing OT PT and ST. He has Medicare A, B and the private Unitedcare that is paid thru his employer as a retirement benefit.
I’m very confused as to why he is not able to stay. The social worker said they will try to see if he can go to a skilled nursing facility. Also they contacted palliative care? And they were talking about getting him Medicaid? He lives at home with my mother who is strong and healthy. I am here to help as needed.
Who do we contact to fight this? He has heart issues (a fib) so his blood pressure gets very low when they have him try standing but he’s doing it and then at times can get high. They are working on getting him the right meds to get it more regulated.
I would think with all his insurance he would be covered. He has made progress considering the surgery’s he had. They said it’s just going to take a long time. I’m right now trying to fight just to let him stay till he can sit up unassisted and 1 person to get him in the wheelchair
Please help if you know who we can contact to fight this
Oh my. I’m so sorry you’ve having to through all of this. it’s really just terrible. If anyone in the community has a suggestion, please offer it. In the meantime, you should do what what you can to work through the provider and insurer.
Having worked in a and before I have some knowledge about how they work. But my friend is in rehab in one now and she asked and was told she’s getting the 500 minutes a week of therapy. That therapy, however, consists of a therapist coming and taking her to the therapy room, putting some weights in her hands and telling her to do exercises. The therapist then leaves and goes to get another patient. When the two therapist have 8-9 patients in the room they start immediately taking the patients back to their rooms one at a time. That is it for therapy! Supposedly this is pt and ot. Is that really therapy? Can they really bill for that?
In answer to your question – “Can they bill for that?” Unfortunately, they can. This is called “group” or “concurrent” therapy and it’s allowed but there are limits. They’ve got to deliver some individualized therapy too. even so It sounds like it’s not a very good rehab facility!
I am absolutely floored by what is going on with Medicare. My mom cannot walk, stand, or transfer herself and needs a 2 person max assist. She can not even use her right arm. She had a fusion surgery and went to SNF after. Medicare will not pay stating she doesn’t need the SNF level of care. Really? She has made some progress in therapy but it is slow going. We just lost the second appeal. So now she has to pay outrageous money to the current SNF and I have no choice but to find a Nursing home to take her. She cannot be home and cannot take care of herself, yet everyone seems fine to just discharge her. Of course finding a nursing home has also been a challenge. My guess because of the fall risk she is too much work. It’s a travesty what is occurring in the healthcare system. It is a crime.
That should say worked in a snf. Love auto spell!
There may be some help coming on the medicare front, for individuals who need non-medical in-home care with Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs.) Starting in 2019, Medicare Advantage health providers will have the option to provide supplemental benefits for these needs. Actual support for these services may not actually become available until late in 2019, or beyond — but it makes sense to investigate the Medicare Advantage plans available from the providers in your area as the annual open enrollment period comes. See if any providers in your area are planning to offer this coverage for 2019, or if they are considering doing so in the future.
MEDICARE COVERAGE QUESTION
My 69 year old wife recently broke her RIGHT ankle as well as LEFT femur. She was in the hospital for 6 days ( femur needed surgical repair) and will be in an Acute Rehab Hospital for the next 2 weeks. She is being advised by the Professionals at the Acute Care Rehab Hospital that although she is in need of further phyical rehab that she should go directly home from their facility rather than to a Subacute Facility because there is a fear of potential ‘infection’ she might get at the Subacute Facility. She’s been advised that ‘infection’ is the biggest risk to her ability to Walk again. The problem is that she would be home unable to put weight on either leg for 6 to 8 weeks due to the severity of the injury.
The question is: if she came directly home from the Acute Rehab and found within a week or so that it is not workable, could she take the infection risk and enter a Subacute Rehab Facility and have it paid by Medicare as a continuation of the original accident and hospital stay?
Brian – As long as the admission to the subacute (“skilled nursing facility”) is within 30 days of discharge from the short-term inpatient acute care hospital (i.e., not the inpatient rehab facility), she will qualify for full Medicare coverage of the subacute stay for the first 20 days. (After 20 days, there will be a copayment). The only caveat to this is that, in order for Medicare to cover time in a subacute following a hospitalization, the initial hospital stay has to have been at least 3 days long and not an “observation stay.” Happy to discuss further if you’d like to send us your email address through info@daughterhood.org – Anne
Hello, my 92 year old mom has Medicare Part A and Blue Cross/Blue Shield Part B – she fractured her pelvis and fractured her shoulder – specifically the caracoid process . She fell at my house where she lives with me , my husband and 14 year old daughter – we brought her into ER and they wanted to send her home but said they she would be eligible for a rehab facility but that it was up to us as to what we could do – my husband is disabled and I work full time therefore we could not take care of her at home . The hospital er admitted her and put her on an observation list not inpatient. We asked about a rehab facility and they said she was not eligible for it because they don’t consider a broken pelvis and shoulder a necessary reason to be in a rehab. I’m disgusted with this decision and don’t understand why she can’t rehab at a facility. They said maybe she can go in as a Medicaid pending patient depending on her income – which is very low and no home, car and a meager amount of money saved for hearing aids or whatever else she needs. Please advise – thank you so very much. I am so broken hearted with the system.
Hi, I have a question about my mom. Something similar may have already been asked, but I would like to know what can be done. My mom had a stroke, very severe, she has made a lot of progress. She has Medicare A and B, and they paid for somewhere in the 90 day range in this rehab. She has maybe 1 week or 2 left before they discharge. They said she will not be able to be on her own right yet. They got her to the part of being able to eat on her own, and take a few steps being helped. Neither me or my brother can afford to stop work and stay home, my dad passed away, she is 66 years old, and all the hoops to get Medicaid is not possible. I have heard if she goes to another facility, Medicare will pay another 90 days, which I think by how she has been improving, may be enough for her to make it at home with assisted help. Is there anything that can help, without selling all the property and all else that needs to happen, but not possible to get Medicaid
Unfortunately, you can’t trigger another 90 days in coverage by transferring to another Medicare skilled nursing facility. The only way to get more coverage is for your mother to go back to the hospital, be admitted for an inpatient stay and stay there for 3 nights. This isn’t a good way to extend coverage because it’s very possible the hospital wouldn’t admit your mother to an inpatient stay unless they thought she really needed it. Your only options are to take time off and help your mom get back to better functioning (which is not possible, I understand) or hire someone to do it in your place. However, you might start by seeing if the nursing home can recommend some at – home options for your mother that could help bridge the gap. They could include Medicare-covered home health, which is not round the clock care but can help her get access to needed therapies (physical, occupational and speech); and private pay home care. This is very expensive but perhaps better than taking time off of work. Given how young your mother is and the severity of her stroke, I suspect you may need to look into what will work for her over the long term. Maybe it’s not Medicaid right away but using her assets to help her finance care somewhere like an independent or assisted living…
I am a daughter of parents who are in their 80s. They both have stayed at SNFs for knee or hip replacements and then went home. SNF care….you will find care both good and bad in all of them. Depends on the individuals. Bottom line….ALWAYS be an ADVOCATE! Be there! Ask questions! Report rudeness or any other problems to the administrator!
That said, I am also a therapy worker in rehab dept of a nursing home. We are restricted to insurance and Medicare etc. That said, this is why I’m anonymous….therapy and the facility will try to keep your parent beyond reasonable benefit!
my dad is 90 and fell, breaking his wrist and femur. He’s in a rehab, which I now realize I don’t know which of your two categories it’s in. I’m worried he won’t even get the three weeks you describe as typically covered — he’s been in only a week, clearly not ready to leave (even with the frailty and limitations you describe which will still be present in two more weeks). The facility describes the hurry as insurance-driven, despite his doctor’s rec. Is there any way to fight for at least this minimum coverage? Thanks for your clear information and ongoing answers, how kind.
So sorry about your Dad. I suspect the rehab he’s in is the skilled nursing facility. Based on what the facility is telling you, it sounds like he gets his Medicare through a Medicare Advantage plan (see this blog: https://www.daughterhood.org/making-medicare-choices-for-your-parents/) . The health plans do have a tendency to approve shorter lengths of stay than traditional Medicare. Let the facility know that you would like to appeal the “coverage decision” with your Dad’s insurance company, and ask for their assistance. Maybe they can run interference for you. Otherwise, follow the instructions on the CMS website here: https://www.medicare.gov/claims-appeals/file-an-appeal/appeals-if-you-have-a-medicare-health-plan
Twelve days ago I entered my Mom into a nursing home temporarily. Went to take her out for two or three days,Christmas Holiday, and they tell I cannot because Medicare won’t pay if she is not in her bed before midnight. What’s up. She is not in there permanent. What the heck is going on.
This sounds strange to me! Medicare won’t pay for a nursing home stay at all unless it’s following a three day stay in a hospital. In that case, if your mom goes from the hospital to the nursing home for rehabilitation, the Medicare coverage is really intended to just be for the purpose of rehabilitation and if she’s discharged, that’s the end of the stay – sort of like how a hospital would work. Is it possible your mom was admitted into the nursing home using Medicaid? Or possibly she’s on a Medicare Advantage plan and the insurance company approved the Medicare covered nursing home stay without a prior hospitalization?
My husband was admitted to a SNF for rehab following a 10 day hospital stay after a fall at home. During his hospital stay, he was found to have a urinary tract infection and a perforated gastric ulcer. He has multiple health issues and all this left him very weak. After he was admitted, he developed C. difficile and spent 5 days in isolation. He received limited therapy during those 5 days. His Medicare plan gave a discharge date of 2 weeks from admission and a request for additional days was denied. My husband just wants to come home and refused to file an appeal. I understand that he can be readmitted to a SNF within 30 days without a 3 day hospital stay. I’m not sure he is ready to be home. How does one go about doing this?
Hello, i.amost and distressed and don’t know how.more to advocate for my dad for higher care. My dad has been in the icu now 20 days went in for pneumonia and now has had dialysis, a ventilator, trachea a peg so many other things poked and place and all while sedated.
Now.it’s time for weaning him.and talks about transferring him to a long term acute care hospital which there aren’t any of I am finding out. The 1 that’s close to us has a ridiculous term that we have to sign ans agree on which states if dad is not better (weaned off of trachea and or dialysis) he will need to be transferred to an out of state facility because california doesn’t have any facility which can take care of a patient who is undergoing dialysis and is on trachea.
I am baffled yet don’t even know where to turn to ans how to handle this now. Out of state? How and who …so my question is who can I ask assistance from regarding being an advocate plus finding other facility that would take dad if that worst case scenario did happen.
I.am feeling helpless and lost.
HI MY NAME IS CARMEN GONZALEZ. MY HUSBAND JOSE AND I WERE BOTH HIT BY AN AUTOMOBILE ON OUR WAY TO WALMART. WE WERE PEDESTRIANS AND HE WAS THE ONE THAT SUSTAINED SURVEY INJURIES. THE DOCTORS GAVE HIM ONE YEAR TO LIVE. BUT HE IS STILL ALIVE AFTER 11 YEARS. HE NOW RESIDES IN A NURSING HOME UNTIL I CAN BRING HIM HOME AGAIN. THE REASON FOR MY LETTER IS BECAUSE I WANT HIM TO GET PHYSICAL THERAPY. THE STAFF ASK HIM IF HE WANTS PHYSICAL THERAPY AND BECAUSE HE SAID NO THEY DO NOT GIVE HIM THERAPY. THEY TELL ME IT IS THE LAW. THEY SAY THAT IF A PATIENT SAID NO THEY DO NOT GIVE HIM THERAPY. I AM HIS HEALTH CARE SURROGATE AND I HAVE A DURABLE POWER OF ATTORNEY. IS TRUE WHAT THEY SAY THAT IF HE SAID NO THAT THEY DO NOT HAVE TO GIVE HIM PHYSICAL THERAPY EVEN THOUGH I WANT THEM TO GIVE HIM THERAPY. EVEN IF IT IS RANGE OF MOTION.
THANK YOU.
Hi – Carmen, there’s a difference between having the power of attorney – which means that you can make decisions for him if he’s incapacitated – and being a person’s guardian, which means you make all decisions regardless of a person’s wishes. If you don’t have guardianship and want it, you needs to talk to a lawyer.
Hi Anne,
Thank you so much for all of your information. My 85 year old Mother had knee replacement surgery 3 weeks ago. She was in the hospital 3 days and then came home where she lives with me. I asked and asked for her to be admitted to a skilled care facility for rehab as she is very frail and weak. It was to no avail as she came home. It took the last 3 weeks just to get her pain under control. She is progressing very slowly and is now becoming depressed. Can I contact skilled care places myself? She did skilled care after her back surgery and rehabbed beautifully. This is becoming a nightmare. I don’t know where to turn. The only assistance she receives is PT twice a week in home. She is wonderful to Mom, but it’s not enough. I just know she needs more help than what I am doing here at home. She responds much better to the professionals with exercise and therapy. Can she only go to skilled care or a rehab facility right after hospital release? Does a physician have to sign an admission form? Thank you for your help. She has both Medicare and supplemental insurance. D
If your mother was in the hospital as an inpatient (not on an observation stay) for at least three nights, she technically had a “qualifying hospital stay” for the skilled nursing care, and is entitled to the skilled care in a facility for up to 30 days following the hospital discharge. I recommend trying to call some skilled nursing facility care locations in your market to see if they can provide guidance.
Hi Anne,
Thank you for this blog! I wish I’d found it months ago! My mom needs her hips replaced, she has arthritis and can’t walk without excruciating pain (she has a scooter now). The doctor is telling us because this is an elective surgery she can’t go to a SNF so we need to arrange care for 7-10 days. She’s blind and takes a lot of medication, so she’ll need a lot of assistance. She’s in assisted living and I live 150 miles away, so I’m not an option. If she’s in the hospital for three days will she qualify for a SNF? If she isn’t, do you have any ideas about what we could do for a caregiver? I’m at a complete loss. She has Kaiser Senior Advantage and Medicare A and B. Thank you so much!
Hello, Will Medicare pay for in home therapy (PT/OT) for my mother if her home is in Delaware but she’ll be staying with me in Pa?
She’s had another stroke in July and isn’t progressing well and I was told today that medicare may “give her the boot”.
Her husband is of no help whatsoever. I just want her to be safe and comfortable. She can speak sometimes but doesn’t always. She hasn’t been able to stand yet and keeps trying to get out of the wheelchair when they’re taking her to PT (after 2 weeks of quarantine bc of covid. So that’s 2 weeks shot, yes they did pt in her room but……
Your mother is entitled to Medicare home health benefits, regardless of where she is located… so it won’t matter if she’s not at her primary place of residence. But, she’ll have to qualify for the benefit – meaning needing a skilled level of care and being mostly homebound, which it sounds like she is!
If your mother is in a “Medicare Advantage” private insurance plan, it might be a good idea to call and confirm benefit eligibility and let them know your mother is located in a different place. Also, you should go ahead and ask the rehab center which home health agency they recommend and start looking at the agencies!
She was in the hospital for 5 weeks and is now in a “rehab” facility
My husband is 92. He is in a nursing home faciility for physical and occupational therapy for his legs that became too weak to hold his weight up. He has been there about 6 days now and he wants to come home, he is very depressed. I had a conference call with the social worker and therapist to discuss the issues and asked if my husband could be discharged to come home, since home therapy is ordered and I have made the necessary preparations for him to come home. They said it was against there medical advice to do that, that it wasn’t safe yet for my husband to come home. I even would cover the cost of medical transport to bring him home safely. They said that he could choose another care facility to go to for his physical therapy. They said that his insurance may not cover his medical if he choose to discharge agains their wishes. Would insurance still cover all of medical up to discharge? My husband is so depressed and I am very concerned. Can I communicate my concerns with our family doctor and see if he can discharge my husband from the facility to come home and do home therapy, rather than at the facility..I don’t think that my husband will improve that much. I am very concerned about his mental well being right now. Please give me some good advice
can I bring this to the attention of our family doctor and see if he can discharge my husband and get him home fhis therapy..or
Linda, There is absolutely no truth to the statement that you would lose medical coverage if you bring him home against their advice. It is 100% your decision and Medicare coverage of services does not depend on whether you follow their advice. If you feel like it’s best and you’ve arranged for at home services, then you should follow through with your plans. You deserve an enormous amount of credit for doing such a great job advocating for him and writing to us to get information. Best of luck and please keep in touch if you need anything else.
Hi, thank you so much for this thread. My friends mother fell twice in her nursing home in 2 weeks: she has severe dementia. Her first fall a broken wrist second fall required a 10 day hospital stay and surgery for a broken femur. The nursing home she was in was $5500 a month. She was transferred to another nursing home is Colorado and quarantined for 14 days getting little rehab. Now there is a number of patients and staff with covid so they are keeping in her room. She has had a number of falls because with her dementia she feels she can still walk. She required an X-ray in the middle of the night but they says she is fine. She was walking before this all happened. Now the nursing home she was previously refuses to take her back. She has no choice but to keep her in the nursing home she is in and now after the 29 days they are charging her a whopping $8800 a month. Her funds will only last another 4 months. My friend indices in Hawaii and has a number of health problems herself so cannot take care of her. She is on a very small monthly disability.
The nursing home says all they can do is check on her mom every half hour and they have lowered her bed and have a mat for when she falls. If is there anything we can do. It’s sounds like copay would be more reasinabke and she does require more therapy. Thank you
So it sounds like your friend’s mother has run out her MediCARE Part A covered rehabilitative stay and is now in the nursing home as a “long-stay” resident paying privately. Just generally, her Medicare health insurance will pay for rehabilitative care in a skilled nursing facility following a 3 night inpatient stay in a hospital. Unfortunately it also sounds like your friend’s mother missed out on the benefits of intensive rehab because of COVID restrictions. Now she’s paying privately and maybe not getting the rehab she really needs as a “resident” rather than a post-hospital patient. What I can tell you is that your friend’s mother should qualify for continuing rehabilitation therapy under Medicare Part B outpatient therapy. This means that when she switches out of the Medicare Part A, post-hospital rehab coverage, and starts paying privately for the room, board and care, her Medicare Part B will pay for therapy. Now this assumes your friend’s mother has bought into Part B, which requires a monthly premium. So that will cover the therapy. As for the ongoing $8800 room and board, when she runs out of private funds, she will likely qualify for MediCAID coverage. This is a program that covers long-term care for older adults when they run out of private funds. It’s really sad that it has to come to that. I wish our system worked differently and much of our work is focused on advocating for better system and programs. You are a very good friend. There are a lot of details here that may vary depending on your friend’s mother’s situation so please feel free to get in touch with follow up questions.
I have a different comment. My mom has been in a nursing rehab facility for over 2 years after suffering a brain aneurysm/stroke. Her Medicare doesn’t want to cover anymore therapy because she complains that it hurts. I told her that in order for her to come home, she needs some sort of therapy. How do I go about getting her the therapy she needs? To get her on her feet. I can’t get into her facility to see her properly or we would move her ourselves.