goodenergy Asked September 2015
My Mom is in post-surgery rehab in a NH. They are recommending she dis-enroll from her HMO for coverage after day 21. Suggestions?
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Is there any downside to this? Can she obtain Part D drug coverage, even though it's Oct 1, and she's in the REHAB part of the nursing home?? She can't utilize nursing home Medicaid because she needs all her Social Security to cover rent and utilities for the home she will return to (where I live and am also her caregiver), so she can't pay the spend down.... Anyone have experience with this??.... (note: she is also in the process of obtaining community Medicaid through a pooled trust, which should kick in before the end of the year.)
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Here's my guess …..Your mom has a HMO as her health insurance, right? If so HMO are closed systems for service providers…you have to get your care from within the HMO system. That is a lot of what the cost efficiencies of HMO's are about. It's somewhat different than having a BCBS or United or other health insurance plans as with those you can see a provider out of network but that will cost more but your policy will still cover some of the charges. But with HMO's, often you have to stay within the HMO affiliated hospital and its contracted providers for paid by the HMO coverage. HMO's are geared for folks who need more traditional health care with a strong preventative medicine approach.
A NH probably isn't going to have providers within the HMO's system.
If mom is low income, Medicaid is what is going to be the best to pay for her care for a NH stay. Medicaid is going to pay for her room & board @ the NH and the providers who see patients in a NH are going to take Medicaid & Medicare. If mom is really low income, she is going to qualify for "extra help" aspect of Medicaid which covers Rx charges that might fall outside of Medicare Part D or outside of what Rx coverage her insurance allows.
If mom doesn't have coverage the costs of her care @ the NH could easily be 10K, 20K in a few weeks. The C-diff drugs alone can be very expensive.
I would suggest you try to have a clear conversations with social worker @ the NH and the medical director as to just what the discharge plan s looking like for mom and if its realistic for her to return home. Often if NH residents can't get rid of C-Diff they get readmitted to an infectious disease ward @ the hospital.
If it starts to look like moms level of care needed is best taken care of in a NH, then the reality will be that she will need to apply for Medicaid to pay for the NH as you all don't have the ability to private pay. If you are in the situation that as moms caregiver, you are dependent on her stable income from her SS & retirement to make ends meet in your household, then mom needing to stay in a NH, is a total panic situation for you as there will no longer be any of moms income. If that could be the case, you need to start looking for subsidized housing for yourself and get on lists for them ASAP.
If mom is able to return home, try to find out what the base income is for the pooled trust. I'd bet it is about $ 750 or $ 800 as that seems to be the federal standard for disposable income. If so, all moms income above $ 750 has to be paid to the trust & mom has to submit all bills in order for trust to pay those bills. If any of your bills are paid from moms income, those can't be paid by the trust. All you all will have is the $ 750 or whatever is the disposable income amount for your state. For a caregiver who is not working, has no real income or retirement, this is a panic situation. If this could be you, think about what you need to do now to help your future when mom is no longer there.
If she has $ left each month in the pooled trust, I'm pretty sure that $ stays in the trust and all reverts to the pool to pay for others upon her death too.
I'm just wondering if this is being promoted to be done as the medical she is using is out of network for the HMO, so it's more about their being able to bill for services. Most vendors at a NH I'd bet are not within a HMO network but are for traditional Medicare.
Goodenergy - try to clearly find out what the status is on your mom's "progressing" and ability to return home. Also if you need your mothers home to have someplace to live, realize that if she goes onto Medicaid if over 55, her home is subject to Medicaid estate recovery after her death. This is required Not just for NH Medicaid but for a whole group of Medicaid paid for community base services as well. Now there is a caregiver exemption, but you will have to apply for it and provide whatever documentation your state requires for the exemption to recovery.
The NH says if she goes on Medicare, she can get a (can't remember the word, it's similar to Poverty or Need) Exemption for the $100+ day after day 21, so she won't have to pay the co-pay. The reason she will probably have to stay for a few more weeks is because she went there for rehab, but has been bedridden with a c-diff infection she got in the hospital for the 2 weeks she's been there! so not much rehab has been achieved (to put it mildly). She has, however, progressed from being flat on her back sleeping all day to now being able to sit up in the wheelchair and go to the dining room, so that is good.
She doesn't own her home; we rent. I don't have money to pay the rent if they take a spend down from her Social Security, that's why I'm not applying for nursing home Medicaid.
Does this make sense in terms of your knowledge?
In L's case he has Medicare as his primary coverage and federal retiree Blue Cross as his secondary coverage. Anything that Medicare does not pay for is then paid by Blue Cross. My mom only has Medicare administered by UHC and her coverage is not nearly as good as L's.
The rehab is giving her an exemption from all co-pays due to poverty. They can do that with Medicare, but not with an HMO. That is how this whole thing got started. And I am really grateful for that!!!!!!!!!!! She does not have the money and simply could not pay for any co-pays, but it's a pain to deal with bill collectors who are trying and trying and don't like no for an answer. So grateful to be spared that.
I did an online chat with Medicare.gov so I could have everything in writing, as her insurance company said she would not be able to change plans until Jan 1, which is obviously just wrong.
Medicare.gov quoted the regulations that if you are in a rehabilitation facility or nursing home you can change plans the month you are admitted, and the new coverage will start the first of the next month. They also said go to Medicare.gov and sign up for a Part D drug plan. That will automatically take her off the HMO and into Original Medicare. So I did just what they said and got a confirmation number that it had gone through.
She doesn't qualify for Medicare drug "Extra Help" because her income is $50 over the limit. Really. Not kidding.
In some ways Medicaid would be a better solution, but I have not been able to get good information how applying for nursing home medicaid would fit with her already underway application for community Medicaid with a pooled trust. I will continue to look into that if I need to, if it turns out there are too many uncovered costs. Though I don't foresee that, according to what the rehab finance dept told me, she should be covered up to 100 days.
She has been exercising with the PT 5x/week in bed, and has been progressing, thank God.
Glad to have this place for support. Makes such a difference! Thank you all again.