Extended care: What does Medicare cover?

Thank you so much. It's much clearer now. It's still a confusing time, but it helps to know she'd have coverage to an extent, and then, Medicaid, possibly as an option. She's been in the hospital since the evening of Oct. 31 so she's definitely past her three day minimum. Social worker is contacting a few places -- I told her about my mom's insurance situation, which is that she has no supplemental coverage, just Medicare A&B (she cancels supplemental insurance after a couple months, always, saying it'll be cheaper for her not to have it. I disagree, but so far don't have the power to do that.) She's improved a lot since she was brought in Friday which is good, but she's also extremely hostile right now. Mostly she's mad she isn't getting her xanax dosages the way she doses herself at home. (I think she may have taken three 1-mg Xanax to zonk out and maybe fell as a result ... maybe. I know she likes to take more than a pill at a time. And yes, I've mentioned it to her doctor repeatedly!) As she feels better it's going to be harder to convince her to go to a facility for a week or two. That's a big concern now. But the hospital seems willing to help advocate to get her into rehab instead of just letting her flee. (She's already demanded I bring her clothing, which screams of an escape plan.)

About Medicaid & AL payment, all states have the ability to do a diversion of Medicaid funds to other sources of care than a NH as there can be significant cost savings in doing this. These are Medicaid Waiver Programs. The PACE program is a Medicaid diversion to keep them out of the NH and stay in the community. Some states have a Medicaid Waiver program available to AL for a set # of beds that Medicaid will pay for. It seems to be that these AL are those that also have a NH section within the facility as well & I bet this is a requirement for participation in the diversion so a resident can move to NH asap if something happens.

But most AL are freestanding, for-profit & private pay or LTC insurance.

If she is on MediCARE & was hospitalized for a stay of 3 or more full days and then discharged from the hospital to "rehab", then the "rehab" is a MediCARE benefit. The benefit is automatic for the first 21 days; then after that they need to be "progressing" in order for MediCARE to pay a % of the stay (I think it's 80% Medicare & 20% patient and if she has a secondary insurance policy they pay the 20%). The "rehab' can be at a speciality facility or within a skilled nursing facility (an SNF aka a NH) that has a rehab unit. It would kinda be rare for an AL to have a "rehab" sector, so the social worker is probably looking at placement in a NH.

Now what happened for your mom is the overwhelming scenario in how the elderly enter a NH: mom/dad living @ home, falls; goes to hospital; gets discharged for rehab; doesn't progress in their rehab, so Medicare stops paying; they can't go home as they can't function as they did before so stay in NH; neither family or the elder has the $ so they end up applying for Medicaid to pay for NH.

NH is either private pay; long term care insurance or Medicaid. A NH does NOT have to have Medicaid beds either - so you want to make sure that wherever moms is placed does take Medicaid and takes residents as "Medicaid Pending". Most of the better NH where I live (New Orleans) do NOT ever take Medicaid OR they take it for just a few beds and the waiting list for those is always made up from private pay residents who have been there paying for 1 - 2 years prior. But where my mom is in Central Texas, there are lots of nice NH that take Medicaid. If you think that mom will need to apply for Medicaid, please make that clear to the social worker @ the hospital. NH run between 5K - 15K a month. Really depends on your state. Now the NH all really really like taking them in for "rehab" as Medicare payment is pretty high so that part will be easy. It is how the NH deals with Medicaid once she goes off "rehab" that will be sticky.

Basically for Medicaid, they have to be impoverished with about 2K in monthly income and 2K in liquid assets. They can keep their home & a car. It's going to be a lot of hoops to jump though, but really some of this panic on Medicaid can wait.
Get a short list from the social worker of the rehab's who have current openings and go see them asap. Tour each and find out if they do Medicaid Pending and get their list of what they want to see to accept mom as a Pending. Don't hyperventilate when you get the list, it will work out. Pain in the butt but do-able.
Personally I'd more concentrate on working, encouraging mom to do whatever in her rehab to be "progressing" so that she is getting to be her old self and also that this is all about Medicare paying for a close to their 100 days maximum. Having Medicare paying for mom gives you time to deal with the whole Medicaid qualification and application.

Also keep in mind that MedicAID is run by the states, so each state has it's own unique rules but within an overall federal guideline. We dealt with Medicaid for my MIL in LA and it was some kinda simple compared to what my BIL had to deal with for her when she stayed in TX. Your state should have details on Medicaid on their HHS (Health & human Services) website or Department of Aging site. It's a lot of take it and try not to let it overwhelm you. Good luck.

The skilled nursing care and PT at a skilled nursing facility (SNF) will be covered with no co-pay for 20 days. Medicare will cover the services for another 80 days with co-insurance. BUT... two important questions to ask:
1. Was she actually admitted to the hospital she is currently in -- as opposed to just being observed -- and has she been admitted for three nights (as opposed for example to observed for a night and admitted for only two nights)? If she does not meet both of these critieria, Medicare will not cover any of the SNF charges
2. Make sure you understand the care plan for the SNF. The 100 days are not automatic; she has to be making progress toward recovery (or continuing to need the skilled nursing or... whatever the plan says)

Medicare does not cover assisted living and "senior homes."