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Rehab Nurse Shares Insight: Medicare/Advantage/Medicaid

(Part 1 of 3 narratives adapted from an interview)

Good morning, everyone, this is [Erin Fountain] and I’m joined today by Ilona Weber, who’s a nurse and she’s going to give a few pieces of insight with comparing traditional Medicare to alternative plans especially when considering long term care assisted living or Rehab Facilities. And Ilona, thank you so much for sharing your time today, I really appreciate it. I know that when we spoke earlier, you had some experiences that you wanted to share from you having been a nurse and seeing kind of what can happen. I know that you’ve worked in geriatric medicine, long term care facilities and various capacities for over 25 years. So, in your opinion, in your experience, what kind of forewarning and information would you like to share with people?

[Ilona] Okay, first of all, coming from somebody who has worked in rehab and nursing facilities, I Just want to let people know that traditional Medicare does pay for 20 days upon admission. If a patient needs to stay beyond 20 days, their copay will kick in on day 21. The copay may or may not cover 100%, it may cover a different percentage. Medicare does not pay for long term care. If they are unable to take that family member out of the facility because more care is required than they can give, family members need to go to the Business Office and start the Medicaid process. If a patient has a Medicare Advantage Plan, meet with the Business Office to find out about how many days their insurance will cover while in rehab and what it doesn’t cover. If they feel like they cannot take this person home, say this person’s had a massive stroke and the caregiver or their spouse cannot care for them because it’s just too much, they need to immediately start asking the business office for assistance to apply for Medicaid. If they are incapacitated and need equipment at home to assist in their care, speak to the therapy department on their recommendations and coordinate their needs with Social Service so you will have that in place. Not all equipment is covered under Medicare.
It has to do with a lot of assets. You need to bring your assets into the office, and they can streamline you and work you through this process. But it is a process – you have to have necessary paperwork with you: your checking account, any kind of IRA that you have, any kind of pension that person has. They have to see the total assets including the value of your home. No one’s going to take your home away from you, but that is considered an asset when applying for Medicaid. It is a long process, and the Business Office is there to guide you with that journey.
Typically, it’s 20 days after an event in the hospital. Then 20 days is only three weeks. Straight Medicare may allow additional days after Day 20. If you have a copay with traditional Medicare, you can qualify up to 100 days at a rehab facility, IF THERE IS A REASON FOR YOU TO BE THERE (like you are improving in your therapies, or you are on IV antibiotics, or you had a setback) If you have a Medicare Advantage plan like a Blue Cross or an Aetna, then you typically get those 20 days, maybe, it’s not set in stone, and then on day 21, there’s typically a copay, which is anywhere from $125 a day and up. And then after that, after Day 21, there will have to be documentation sent in by the facility (and they know this) about the progress being made from nursing and or from the therapy department.

If the insurance company feels like progress is not enough or they are not participating, they can issue a letter of non-payment and that person will have to be discharged. So, it’s something that can happen in five days. You can get a phone call saying, “Well, your mother’s coming home tomorrow or your mother’s coming home in four days. And not to be shocked, this is very normal. You can appeal it. If you do appeal it, you get an additional 5 days. The Social Service Dept at the facility will inform you of this. The insurance company will, may or may not, make you pay those five days if the appeal was denied. So, you have to get that appeal in and need the rehab facility will help you fill out that paperwork. But you have to be on top of this.

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