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Currently, father-in-law is in Rehab Center under 20%pay, Medicare pay 80%. We received notice that he goes on full pay in three days because he is not progressing. There was a legal action taken in December which the patient only had to be sustaining with the help being given in the Nursing Home.

Is this a way that Nursing Homes make money considering full pay is more than what Medicare pays?

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NH have to abide by whatever the Medicare rules are when the person is being covered by Medicare. Medicare is only for short term health costs. Long term care is not covered by Medicare. Once Medicare is over (or if admitted "Medicaid Pending" and Medicaid is declined), then the facility can charge as per whatever rate was indicated in the admission contract.

So is FIL going to apply for Medicaid?? If so, then you want to have FIL apply to stay as "Medicaid Pending" and the daily charge will be at Medicaid rate. But if FIL cannot qualify for Medicaid, NH can bill at their private pay rate. You might want to look for another facility, if this is a true rehab place (the kind that has lots of younger trauma cases) then often the level of care is very specialized and very very expensive as compared to a more traditional NH with a "momma broke her hip" rehab room.

For Medicare rehab, the rules are very strict as to the person's "progressing" with the PT & OT having to document their treatment, weight, pain and rep's, etc and the MD's orders done. I imagine there is a formula that is used. If they aren't progressing by week 3 / day 21, you usually know they are about to be removed from Medicare paid rehab. It seems to be done every 3 weeks so they can either be accepted or declined for another 30 days.

My mom tore her rotor cuff and had surgery and did PT/OT for 4 months and the 3rd week of each 30 day cycle would be evaluated for her "progress". At 90 days Medicare would not pay anymore but the PT thought she would do well for another couple of months, so she did it and it was covered by her BCBS with the balance private pay but at whatever BCBS did not pay. That was in the contract that her responsibility was at whatever the difference was. Now BCBS negotiates prices maybe 20% less than full private fee so that was good. But PT/OT could have charged their full private pay rate otherwise. After month 4 she could roll her hair and that was her goal, so she stopped rehab. You carefully need to review the admissions contract to see what was agreed to.

You do have a copy of it and all the other admissions documents, don't you? If not, then you have to go to admission to sit & wait to get this, and yes….they can charge you a fee for providing the copies. Sometimes the documents get scanned, so they can send you the document via email for no charge. Good luck.
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also Olivia, if FIL goes in Medicaid Pending, he will have to pay all his monthly income to the NH as his co-pay under Medicaid rules. This is called all sorts of things, like resident responsibility, their "SOC" (share of cost) but is required under Medicaid. Sometimes this comes as a total surprise to family.

They do get to keep a small allowance each month - the amount depends on the state and is from $ 30 - 90 a month. Some facilities press upon family that the allowance is kept @ the NH in a resident trust account too. I don't do that with my mom's allowance but I'd say 80% of the residents @ her NH let the facility get their monthly income directly. So for us, my mom get's $ 800 from SS and 1K from retirement, monthly income 1800 and her personal allowance is 60, so each month I have to write the NH a check for $ 1,740.00 from my mom's checking account in order to be Medicaid compliant. Each month her checking account builds by 60 and I do have to be careful that her checking account never exceeds 2K as that is the Medicaid limit on assets (the NH monitors this for those that get the allowance put in their resident trust account @ the NH).
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My husband read on Medicare's site that if a facility is either rehabbing or sustaining resident, the resident qualifies for Medicare. A client whose health is being sustained should fall under the 100 day Medicare coverage which is 80/20. The NH is saying not. They, and most anyone we talk to, says the resident must be rehabing. That is what the December judicial case decided for the plaintiff who took a NH to court. I will see if I can find the case. Thanks for taking time to respond Igloo572.
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Olivia - are you talking about the 60% compliance rule for in-patient rehab? I don't think CMS has the regs out on that yet.
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OK I bet your talking about the Vermont case? It's the Therapy Plateau case. Yeah that is about overruling the Medicare "progress" rules but seems to be geared to those still in the community who have MS or Parkinson's who could benefit from therapy indefinitely. For NH, they still are limited to 100 days and it has to be medically necessary from a hospitalization of 3 or more days. I bet that if they are not "progressing" than neither the MD @ the NH nor the PT (who usually is an independent professional) will sign off that it is still "medically necessary". So Medicare can't pay.

I would suggest that you have a frank talk with the PT & OT to see what FIL is doing and what their viewpoint is on the situation. It may be that FIL is just unable to do what he needs to for PT or OT or whatever rehab he is on to be worthwhile. Ditto for a talk with the medical director @ the NH. My mom was OK for surgery & rehab when she tore her rotor cuff years ago, but last June she fell & broke her hip @ the NH. Although she could have undergone surgery just fine, there is no way she could do rehab. She doesn't have the cognitive ability for PT or OT.

I bet this is why it's being declined. You know none of this is easy, nor is there really any centralized FAQ's for any of this……..not fun.
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A LOT of rules changed on 1/1/14 for Medicare. The 100 days became 20 days. OUCH.
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The case recently won that lead to clarification of the medicare standards is Jimmo vs. Sebelius Settlement--info can be found at this link
http://www.medicareadvocacy.org/medicare-info/improvement-standard/
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Jimmo case applies to medically necessary care whether rendered at home, in an out patient center or in a nursing home . Please google Jimmo settlement or click on link given by earlier poster to read your rights. The no progress approach is clearly no longer a basis for terminating care, so long as other Medicare eligibility requirements are met. The link cited above should give you all the info you need.
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from the link:
"Thus, such coverage depends not on the beneficiary’s restoration potential, but on whether skilled care is required, along with the underlying reasonableness and necessity of the services themselves. The manual revisions now being issued will serve to reflect and articulate this basic principle more clearly."

what I bet is going to be the hurdle is the "UNDERLYING REASONABLENESS AND NECESSITY OF THE SERVICES THEMSELVES". The question is going to be is it reasonable to continue to provide PT/OT for a NH resident who is latter stages of dementia, already cannot do their ADL's & does not have the cognitive ability to participate in their care. That is very different reasonableness than continuing to provide for PT/OT for someone with Parkinson's or early stage dementia's who is still living at home and can do their ADL's.

If the medical director & the rehab therapist do not consider the care to be "reasonable", then they are not going to write the orders and Medicare won't pay. The code word is going to change from "progressing" to "reasonableness".
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Igloo is correct. The individual needs to continue to demonstrate a skilled need, which is documented by the therapist or RN. This therapy can take place in the home by a Medicare approved agency or in a Rehab or Skilled Nursing Facility that is approved by Medicare.

If you have a family member that you are wondering about, their therapist or nurse can give you a pretty good idea how long the skilled need will last for the individual.

Medicare is usually intended for short term care. It will not cover if custodial care (bathing, feeding) is the only need.
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igloo572 & kmonksmsn & pstegman Thank you for your information and time. Section 409.32(c) of Title 42 of the Code of Federal Regulations is helpful to add to one's collection of Medicare coverage. The tricky part of this is a need to take a patient off rehab to determine if therapy is the one factor keeping the patient from further deterioration or preserve current capabilities. This is where my FIL is. They have just taken him off this therapy, placing him on full pay/ no medicare. Once it is determined. if he deteriorates or is unable to preserve current capabilities because he is off rehab, they do another assessment to determine if he returns to Medicare assistance. By the way, FIL has rheumatoid arthritis - most of one him is fairly deteriorated and then his shoulders cause his inability to raise his arms above his shoulder. Dementia is tough to determine because he does well at compensating with sarcastic, demeaning yet very rational thoughts.
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So medicare will not pay for a Certified Nurse Assistant to come into the home to help with chores or pets or meals?
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It may be too late for Olivia's FIL, but I urge everyone to get Long Term Care insurance. The younger and healthier you are, the cheaper the payments. Most policies cover custodial care at home or in assisted living or a skilled nursing facility.
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Pstegman- seriously? Only 20 days down from 100??
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If you read the terms of the Jimmo settlement, available on the link provided earlier by another poster, you'll see that the standard for continued care is whether continued care is necessary to maintain the patient's condition and prevent deterioration or backsliding. That is the new standard for reasonableness and medically necessary, and health care providers, who are still unfamiliar with the Jimmo case (as were two of our doctors) should be unformed of this so they can make the proper findings to support an application for continued care.
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To loritabbykat: Medicare will not pay for "custodial care"' meaning cleaning, household chores and such. Medicare only pays for necessary medical care. However, Medicaid does provide aides to help with meal preparation, grocery shopping, laundry,etc, So if the patient qualifies for Medicaid (an income based bpublic assistance program) you can get assistance with custodial care.
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To loridtabbykat and rucabe We will be checking into this. Thank you for your prompts. At this point I believe Medicare paid for the County nurse who stopped by to see both parents before the FIL fell, ending up in NH. loridtabbykat - interesting point. If one spouse goes on medicaid when in NH, and then comes home, would medicaid pay for custodial care for him even though wife, not on medicaid, is still there. She has dementia and inactive so cannot care for him.
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OliviaC, Medicaid will cover custodial care of the eligible spouse,even if the other non Medicaid is still at home but can't care for him. They will, however, limit their activities to the care of the Medicaid spouse. But look into whether the other spouse is eligible for Medicaid in her own right. I would assume that if one spouse has met Medicaid's income eligibility standards, the other spouse is in the same financial circumstances. And, if the other spouse is infirm, why wouldn't you be seeking Medicaid assistance for her as well? Please check this out with a social worker and/or your local Medicaid office.
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I've been mulling Jimmo aka "Therapy Plateau" over and I bet that one of the consequences in changing the criteria from "progressing" to "reasonableness" is going to be that those elderly with advanced dementia may find that they are now not going to get the first month rehab done which was always done and Medicare has always paid for. Likely big bad news for the elderly & their family

I wouldn't be surprised if the view will be that the advanced dementia patient "reasonably" cannot benefit from therapy from the get-go as dementia is considered a terminal disease. If this happens, there will be a lot more elderly going onto hospice (the other big Medicare paid for benefit) upon admission. Now Medicare hospice does not pay for their room & board at the facility (like it does for the Medicare covered rehab period), so the R & B will either be private pay or Medicaid. But for the NH, more hospice is a total win as it brings in additional skilled care for their residents but doesn't cost the NH anything in personnel, equipment, etc as Medicare pays for all that to the independent hospice provider

It's quite quite different from continuing therapy for someone with a chronic disease like MS, CP, Parkinson's, secondary polio affects who has hit a plateau either in their ability or coverage. In my reading of Jimmo, the heart of what was in the case was about those chronic diseases. I could be wrong but I bet this happens

Olivia - would you let us know what happens for your FIL and what the doc's & the PT/OT say? We all learn from each other, thanks oodles!
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To: igloo572 If dementia is considered a terminal disease, then why aren't doctors approving hospice for FIL? He not only has RA but a heart and lung issue along with the dementia. Yet not one medical professional either at the NH or the hospital he was in before going to the NH would write an assessment that he was incapable of making his own decisions. His diagnosis from one geriatric psychologist in the hospital is that he can make simple decisions but not complex decisions. Crazy as this sounds, the NH claims they have seen a decline in his cognitive behaviour too but the therapist is not willing/qualified? to make a medical psychological evaluation. She states that he has reached a plateau.

JIMMO CASE - If he starts to fail when he arrives home, can he go back to Rehab to help him regain what he lost after being taken off of Rehab? When at home, he refuses rehab. He has no clue what this means financially. Once again; therefore, no hospice and no authority for Medical Power of Atty, which is all my husband needs. But it reads only if subject is deemed incapable.
I will let you know as much as I am informed about. I say that only because there will be a lot of information dropping to all parties and I just not be one of those due to my assistance being needed in other areas. THANKS TO YOU ALL!


Currently FIL is scheduled to return home. To: rucabe Our local Medicaid Office is being contacted today. Thanks. An attempt is being made to get as close to in home 24-hour care as possible which NH is in agreement with. Spouse has inheritance which hopefully will remain for her use. Custodial care is all that she needs right now.
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In order to qualify for Medicaid, 2 physicians need to certify that FIL has 6 months or less to live. That may be the reason that your FIL's doctor will not certify him.

With Medicaid, each state uses a formula to calculate the spouse's share of the couple's resources called the protected resource amount PRA.
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