Game plan for skilled nursing with a Medicare Advantage Plan.

Thank you all. She is going to transfer to a skilled nursing facility that she likes (and has friends in). It is the best in town. She is frustrated with herself that she fell again (she was starting to feel like herself again after the sacral fractures). I told her to use the frustration to motivate herself on the PT. I think she will. She is pretty stubborn and motivated. Before the sacrum fracture, she lived on her own, drove her car and did all her normal daily activities. She was cutting back her caregiver time when this fall happened.

In the medium term, she has agreed to move to PHX and I am starting that fun transition of finding a spot, selling her house, and making financial plans. At this time, I don’t know what level of care she will need going forward. Before her sacral fracture, she would be independent living. I’m hoping that we can get back to that, but am preparing for otherwise.

thanks again and I’m sure I’ll stay engaged with this site going forward!

from my personal experiences, the Medicare Advantage company is often aggressive in getting people moved on .

I have had two experiences with my mom . When she broke a pelvis a few years back, Humana wanted her out after day 14 . But the SNF staff was very aggressive and persistant in allowing her to stay a few more days

In my most recent case with my mom, UHC also wanted to push her out. The SNF made no effort to change their minds, so I did. I went through an appeal process and eventually won. My mom did stay in the SNF three more days but had appeal not come through we would have been on hook for private pay for over 1200 bucks for those three nights.

It’s too late to change plans. I get that. You must play the hand you are dealt.
But realize there are thousands of advantage plans. On average an individual can choose between 43 plans.

They are owned by private companies and wherever they set up shop they have x number of primary doctors who accept their plan, x number NH, rehabs, home health, etc. And in my limited experience, just helping out friends or family, they are often not the shiniest stars for any of the providers. So know that one persons opinion/advice about an advantage plan may be very different from your moms plan.

I have a good friend whose sister has an advantage plan and has been going through some of this.

The sister, who has almost died twice in the last 6 weeks due pretty much to not being able to make decisions and very poor medical care, thinks that her advantage plan is great. Her judgement is based on being able to lay in bed and get served tasty carbs in spite of her comorbidities.. She has been in the hospital twice during this time.

She has diabetes, kidney disease, heart issues and now bladder cancer. Doesn’t want to do therapy and doesn’t want to travel outside of her small town to receive better cancer care. Oh and this decision was fully supported by her brother who thinks parking is too hard in the city she would need to go to for better care.

With her plan, one of many that Cigna puts out, she actually has to pay upfront a copay for her rehab stay. $20 a day. They had her pay for 20 days and told her she would get a refund when she leaves if she’s not there the full 20 days. Not a big problem but that’s just a tiny example of how the advantage plans are different from original Medicare. Now this one is an HMO means she has a more narrow choice of providers, procedures etc than your mom might with a PPO. I just checked and she has 17 choices of advantage plans. In a town of 35K. All divided up among United Healthcare, Cigna and Humana.

Medicare covers 100% of first 20 days of rehab. In her small town, pop 35K, county seat in a county of only 85K, she has 3 NHs who accept her insurance for rehab.
BTW, All plans say 100 days but read Igloo’s post about what that usually means.

Two of the three Rehabs had a red hand 🖐️ on their chart on Medicare.gov provider compare. That red hand means abuse has been reported. They have 1 out of 5 stars measuring quality, staffing and state inspections. A 1 means much below average. When the SW at the hospital advised my friend which her sister should choose, she recommended one of the ones with the red hand.

So, you will be able to find this information online and have a little familiarity with the rehab beforehand.

FYI, some will lie about their ratings, say they are unaware, etc. So they leave you with two choices when they make that statement. They are grossly uninformed or think you are. And we all are uninformed on so much when we enter in with our reluctant elder until we get burned a few times.

I hope your mom is one of the exceptions regarding her therapy and that she makes a full recovery.

The good news is she has a part time caregiver which could really help her out. If she could be her cheerleader and be her advocate for getting her pain meds before therapy, her ice or heat or pain patch for after therapy, keeps her hydrated, helps her make choices on eating fiber to keep from getting as constipated, has a good protein supplement to help her heal, give you insight to what is going on, all of that can help mom maintain her sanity through all the difficulties of care and would really be a plus.
I’m assuming she did not go to rehab for the fracture since you didn’t mention that. Just being in the hospital or rehab with no injury can be traumatic enough. Sorry I am such a negative Nelly. Wishing you all the best.

I want to second everyone else here saying that it is highly unlikely that your mom’s insurance will approve an extended time in a SNF. Based on my experiences, they will also limit the choice of facilities and dictate how much home health therapy your mom can receive when she is discharged. Keep in regular touch with the facility therapists and reinforce to everyone her prior level of function— this is a measure which will help justify more therapy if she is progressing. With two major falls, it may be time to look at assisted-living.

Apropos rehab and Medicare Advantage plans, my husband, who had Parkinson's, fell and broke his hip. No way could he have come home straight from hip replacement surgery. He was already using a rollator due to poor balance before the surgery. We had to beg and do several appeals before the advantage company would cover him for a stay in a SNF for rehab; he ended up spending an extra couple of days unnecessarily in the hospital while we were appealing. Then, once he was in rehab, he worked really hard, was making excellent progress, but the advantage company tried to get him discharged and stop paying after 14 days. Again we appealed, and managed to get it extended to 21 days, but he and I decided he was OK to come home at 21 days so we didn't try to get more days beyond that. (We were required to be on an advantage plan because of our former employer, but as soon as they changed that and allowed us to switch, believe me we went to traditional Medicare + medigap and prescription drug coverage.)

Tallen, hope that your moms surgery went well and recovering nicely. Keep communication going to her docs, especially the MD who is the hospitalist for her. Do what you can to have her remain in the hospital for as long as feasible b4 she is discharged to rehab in a SNF.
On the rehab stay, if your expectation is 100days paid by that Advantage Plan, that imho is not going to happen. Rehab tends to be 3-5 weeks tops as they plateau, so rehab ends. Something that can help it go as long as feasible & that you can do is really REALLY encourage your mom to always ALWAYS be agreeable and participatory whenever the PT, OT or whatever rehab staff @ the SNF come to get her. Do your best to be a cheerleader for this even IF you live out of State. Talk with her on the phone, be encouraging. If you know what motivates her, use that to get her to leave her room and go to rehab each & every time she is scheduled and make a diligent effort.

When your mom leaves the hospital, she will exit with a care plan and within the plan will be diagnostic codes (ICD-10 system) for her rehab. For rehab these are measurable and IF mom gets all “maybe mañana” when rehab staff come to get her, this will be written up in her chart. She has got to GOT TO make an effort to work with the therapists. If she is in pain, she needs say something so that her care plan can be adjusted. If she doesn’t make an effort she will get written up as noncompliant for care (plan) and within maybe 2-3 days she will be discharged from rehab. It is exactly as Lea described. Can be appealed but getting the decision reversed will be beyond hard as almost every day there will be details in her chart. Medicare Advantage Plans are very no nonsense on this & will shut down her rehab as soon as they can. That 100 days coverage tend to be done more for a younger and fit 65-early 70’s who is in rehab due to some sort of accident which caused traumatic brain injury which can take over 100 days for their care plan.

Should rehab stop, a decision will have to be made ASAP as to:
1. Stays at this specific SNF and goes from a rehab patient with health insurance paying to then becoming a custodial care resident. Custodial will NOT be paid by her health insurance. Custodial is private pay, LTC insurance (once waiting period past), or she applies for LTC Medicaid program if she is basically impoverished for how most States do their LTC Medicaid program.
OR
2. She leaves the SNF and returns to her prior living arrangement. If her old CG can continue t would be great. If she needs more, then her and you will need to set this up. For the most part In Home Healthcare is private pay. Medicaid programs that will cover IHHs do this within a Community Based Medicaid system and she will have to have an assessment done and then match to a caregiving company that participates in your States IHHS programs. I’ve been on this forum a long time and most of the time it’s in the 22-28 hrs per week range so if she needs more, that’s on her & you to arrange for.
OR
3. She - as per an assessment- is not quite needing skilled care and could possibly go into a AL that has a pretty deep nursing and personal assistance staffing. AL & MC vary by State as to if LTC Medicaid program will pay for it. It’s done via a waiver.

LSS anything Medicaid completely dependent on how your State approaches use of tax $ to do social services safety net. This is really important as you’ll get advice from others that is totally NOT how your moms State administers its programs. #1 takeaway for almost all States is for LTC Medicaid they need to be basically impoverished AND have to do a Share of Cost (SOC) paid to NH of almost all monthly income (like SSA income). SOC tends to come as a surprise. SOC tends to reset plan on elder continuing to keep their exempt as an asset for LTC Medicaid home as family cannot deal with costs & oversight. It’s overwhelming, stay organized and do take time for yourself.

The SNF mom chooses will have to have beds available FOR Medicare Advantage plans, which are different than regular Medicare plans. Only a certain number of beds in the participating rehab SNFs are allocated to Advantage policy holders.

Secondly, mom must continue making progress for the policy to agree to pay for her rehab. The PT and OT therapists have to report her progress, or lack of it, to Medicare continuously. The moment she stops progressing is the moment they release her.

Good luck.

That amount of time isn't being "hustled out". It is, in fact, the amount that Medicare will cover. That means that she must, after that amount of time, be able to return to her former way of living, or she will require placement in long term care facility either temporarily or permanently.

When my brother was in extended care rehab weekly conferences were held with MD, PT, eitary and I was allowed to be there virtually; this is a part of discharge planning. Check your Mom's facility for their own mode of doing things as they move toward discharge, and let them know that you are not living near her, and she cannot go home requiring 24/7 care, so that discharge information is crucial as all of this moves along.

As the time for the 100 days to be over is approaching more near it will be clear to ALL whether going home from this is a possibility. Be ready for anything. Mom may not be able to return to the way of life she was living.
I wish you good luck. I hope this goes really very well for Mom. Letting her know the facts may help her be very engaged in her own healing.