under medicare as it does not meet the criteria for skilled nursing.These services provided were custodial in nature. Ok I get that, he was on medicaid at that point in time so I thought medicaid would pick up the bill. This letter informs me that the beneficiary (my father who is passed away) is responsible for payment to the nursing home services at issue. It also says that his representative which is myself, signed an Advance Beneficiary Notice. I was told all the papers I signed did not mean I was responsible for the bill. I paid a small fee of $45 a month to the nursing home, as that was all I was told I needed to pay after medicaid kicked in. He was there 2 1/2 months. It also said I am not required to take any action, only if I disagree. I don't disagree that he did not get any more skilled nursing as his life was failing, but It makes me a bit nervous for my mother who only has about $9000 in a savings acct. and lives on my dads social security. It also stated that the same letter was sent to the nursing home. Am I to assume that the nursing home will contact medicaid for payment???
OK so dad was on Medicare and then you applied to Medicaid for him when it became evident that he was going to need to stay in the NH, that's the situation isn't it?? And dad moved to the NH after being hospitalized, correct??? Dad got accepted by Medicaid, correct?
If this is the situation, then what is likely going on is that the NH billed Medicare for his room & board & medical services beyond the initial post-hospitalization "rehab" benefit that Medicare routinely pays for. The "rehab" stay that is OK 100% for Medicare is usually 21 days but can go another week or two. It could - in theory - go for 100 days with a co-pay, but I have never known of anyone who got that length of a rehab benefit who was elderly. But Medicare will only pay for his stay under the "rehab" benefit if he is progressing in his rehab. Since dad didn't, Medicare will not pay. He would have gotten discharged from "rehab". Then either his stay @ the NH needs to get paid by private pay or Medicaid. If he applied to Medicaid, then their coverage should kick in the day after Medicare stopped. I would ask the billing dept @ the NH if they billed Medicaid the minute Medicare stopped.
Medicare is totally federal with payment coming from the feds based on whatever set rates for services provided. But meanwhile Medicaid is administered by the states and they tend to be slower payment. Medicaid reimbursement rates are much much lower than Medicare too. So the NH will tend to bill Medicare first & foremost as they make a lot more $$ from Medicare. Anyways, I bet what is happening is that Medicaid reimbursement to the NH has not caught up with paying for dad. Again check with NH billing dept as to when they billed Medicaid for dad's room & board stay. I would send it over as a registered letter after you have called them too.
If dad qualified & was on Medicaid and dad did the required co-pay or his "SOC" - which sound like the $ 45.00 a month you paid, then dad was kosher for Medicaid. Mom should not have any health care bills to pay (assuming the providers all accept Medicaid & Medicare) nor should mom have any MERP claim or lien to deal with (as she is the surviving spouse so there is no estate recovery action). If mom gets a MERP letter, you need to respond to it in pretty short order too - some states have the fact that there is a surviving spouse keyed into their data base so no MERP letter goes out and other states send the MERP letter always. So try to be on the look-out for it just in case mom is too overwhelmed to notice it. Now dad may have gotten some PT or OT services in the NH than came from on outside vendor (that doesn't bill through the NH). If that is the case, they too will get the letter from Medicare that the payment they may have been expecting from Medicare will not be coming, they too should bill Medicaid to get paid. Good luck.
Now in order to go onto Medicaid in the first place you have to be "at-need" or basically impoverished. Most on Medicaid have nothing so nothing MERP can go after. Now if they are married, then the surviving spouse may have assets (your mom's 9K in savings) and those are protected from MERP. Really the only asset they could still have is their home, so then the home can have a MERP claim or lien placed on it. MERP sends out letters to whomever is on file for Medicaid as their contact. Letter is not warm & fuzzy but more like "we're sorry for the death, the state paid $ 68,789.34 through Medicaid and we want to get it back". There will be a response form to fill out that has to be done if you want to file any exclusions, exemptions, hardships. Being a surviving spouse is a full exemption in & of itself. So your mom will qualify for that one. Now some states do seem to have their Medicaid program keyed in to recognize that there is a surviving spouse so those in those states never get a letter. But your state may send a letter (may go to mom or maybe to you if your the contact on file) anyways, so if you all get one you have to fill it out and get it back to the state to close the MERP file. Now some states have outsourced MERP and those are more like a debt collection process……again not warm & fuzzy. They get a % of the recovery too, about 15% for most contracts.
I did a quick search on the Advance Beneficiary Notice for Medicare. Have you read this already?
http://www.medicare.gov/claims-and-appeals/medicare-rights/abn/advance-notice-of-noncoverage.html
Hopefully someone here will be able to help you with an answer from their experience.
For example, who was the "medicare and medicaid service company?" Do you mean the insurance company that handles Medicare in your state? You say "that a 3 week time span that my father was at the NH will not be covered under medicare." Do you mean the other 7 weeks were? By whom? Medicare should not be paying for any of the services if it was not skilled nursing. Ask to see the "Advance Beneficiary Notice" you signed (why not your mother? Did you have his power of attorney?) and take it to the SHIP counselor.
And most important, don't "assume anything." Good luck.
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