My mom was hospitalized for severe UTI (106.7 temp when ambulance arrived @home) for 2 weeks. During her stay, she developed pneumonia, was diagnosed with pulmonary hypertension (4xs normal), her open wounds became infected - she was completely bedridden at her released. Dr. moved her to RH (also a NH) w/Medicare to restore her mobility and provide wound care. She has been there for 93 days, (her last 7 are approved). I applied for her Medicaid a few weeks ago and we are awaiting their decision. Medicaid has not contacted the RH facility for assessment.
Today the RH called and wanted to make arrangements for her copayment ($3900). I was told by our attorney and the RH that I should wait to see what Medicare did, if she was approved it would come back & pick up that cost. In this same conversation, they (RH nurse) tells me that mom will not qualify for Medicaid because does not medically qualify because her memory was intact. Her wounds have healed, but still has a cath, cannot transfer w/o lift & assistance and cannot stand alone, much less walk. Pulmonary hypertension is unchanged. She is getting closer every day, but had a few setbacks along the way. She cannot go back home as she is today and my dad is not in a physical condition to assist her.
Is this a tactic the RH is using to get her copay now, instead of waiting for state to repay? They accept both Medicare & Medicaid. Or do most illnesses/conditions need to be accompanied by memory loss? Is it premature to "disqualify" my mom before Medicare even processes her application?
For us what happend is that the NH or rehab facility, DOES NOT CERTIFY the medical necessity for Medicaid. The state - which manages and administers Medicaid under a overall Federal guideline - will send out a person or a 2 person RN team to evaluate the resident for medical necessity for skilled nursing care.They have a whole checklist to base the evaluation on. That is what was done for my mom for her initial application for NH Medicaid in TX. Now they will go over their chart and take what is in there under consideration but also they do their own assessment. If the NH leaves stuff out, it can be a problem. Like my mom went in and only 1 of her prescriptions were on her chart - why & wtf, right? Well since I brought her in with the balance of her 30 day supply of meds on all but 1, they only put down the 1 they had to order. Nobody read her doctors office records to pull the info from - and her MD was also the medical director of the NH too. It was an easy fix ultimately but did keep her from qualifying because of this and a medical appeal was filed. If she gets turned down, you can file an appeal but the medical ones have to be done by the facility in tandem with family. But the sticky with this is that the facility HAS TO work with you all in wanting to have her there and writing up the chart to show and document "skilled nursing needed".
Is she OK for the financial part of Medicaid? Are her assets and income at whatever your state's level is? Did all the financial paperwork get submitted to the state and where does that stand? Do you know what the date was on that? You can contact the state caseworker directly. The financial aspect is totally on the family to work through the state's system. For us, it seems caseworkers are assigned specific NH's, so it would be that person to contact. If the NH won't give you the contact name, then call your local Medicaid office and just keep asking till you get the unit that has the NH caseworkers. If the NH is inept, then they may not have even sent off the financial in a timely manner.
If you can't seem to get answers from nursing, contact and meet with the social worker. They are a font of information and seem to be rather independent of whatever the NH has as it's company line. Good luck and keep a sense of humor you'll need it!
It is not likely that a nurse would be calling about payment arrangements, and it is not likely that an accounts payable person would have knowledge about whether your Mom was medically qualified for Medicaid.
Wait for the Medicaid response. If they turn Mom down based on the Rehab assessment, appeal. But believe me, memory loss is NOT a qualifying condition!
They did something similar around day 60 when Medicare started pushing for more results from her therapy. The RH wanted me to call her insurance and file an appeal. I explained that once we had a formal denial (the insurance rep verbally said to the RH they would be cutting services off "soon" - but never issued anything in writing). I tried to explain to the RH I didn't feel I could file an appeal if mom hadn't been denied. That took a few days to sink in and hadn't heard another word since.
Mom gets really good care at this facility, but their administrative/front office could use some improvement. I am going up there this morning and will just sit until I can see the nurse in charge of the Medicaid assessment and will ask that we walk through my mom's records to see the best approach WHEN they are contacted by Medicaid.