I posted a few months ago regarding my mother who was found unconscious in a Taco Bell drive thru. She had a stroke back in March and now diagnosed with expressive aphasia, requires two person assist, incontinent, and on a nectar thick/mechanical soft diet and has a g tube for supplementary feeding if she doesn't eat 75% of her food. She went from ICU, LTAC, Subacute, acute, boarding care and now they're recommending SNF. We have been through hell getting anyone to pay attention to her and there were times I had to bribe the therapy team in subacute with Disneyland tickets, bring gifts to the staff and cater lunch so someone would help us. The therapy team also asked me for a Google review after the tickets were given to them so they would look good to their new management.

Back in August, we moved her to acute (thanks to finding someone in the subacute who knew the admitting doctor in acute care) and it was the most active she had been and I was feeling hopeful. However, she was supposed to be discharged home on a two person assist but we realized how taxing it was going to be and thought to send her back to snf to get stronger. The acute team found this and immediately stopped my mom on their rehab program. We then agreed to the family training program for a week but still decided it's too much and moved her to Boarding Care with Home Health therapy. (The rehab PA was angry at us for this and would continually attack us with how my mom's brain is that of an 80/90 year old woman even though she's 75, criticize our boarding care decision and kept mentioning cost, and telling us that we should just take her home)

Things started off okay but quickly went south. Lots of little things including the facility's bed motor sparking with her in it, hoyer lift not working, caregivers were feeding her pureee Chinese food (she's diabetic), and leaving my mom in the middle of the living room in her wheelchair not talking to her all while paying private pay of $5,200 for the first month's rent. However things took an even worse turn as she went into an altered mental state, wouldn't respond and was sent to the ER where they said she was severely dehydrated, had a uti that spread into her kidneys and has been in the hospital for a week now. The doctor said she was so dehydrated, it was like she was stuck in the middle of the desert somewhere. The hospital doctors are recommending skilled nursing as they don't think boarding care has the right resources right now to keep her safe.

Problem comes down to insurance. She has maxed out her Medicare 90 snf days (45 more days till they regenerate) and is Medi Cal pending (lot of facilities won't accept this). However, we found one that is willing to accept us (and has a very good reputation) because i expressed to how incredibly difficult this entire journey has been and my distrust of anyone now. I have advocated for my mom every step of the way because she is my best friend.

Now, I'm not sure how the payment will work but assuming that Medi Cal might cover this but just custodial care. Does anyone know if we go into snf with Medi Cal, would Medicare restart while she's in the facility at some point and we could bill that way for her care/therapy? I believe that part B would pay for some therapy while she's in there too at the start and medi cal would pay for her room. But has anyone else run into something similar like this? What do you think would be a good approach? Should I file an appeal with Medicare that says it's not safe for her to be home as she requires more hands on care to see if that can be approved? Does anyone have any suggestions/recommendations?

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The facility is pulling something very similar to what they pulled on my father when he was in the nursing home then got downgraded from skilled to Custodial (room and board care). The told me the same thing about payment and that he would be discharged if the bills weren't paid in full and cash every month.
They're just blowing smoke out of their a$$es because they won't discharge her if there's no where for her to go or anyone to provide her care.
Next, you would do well to visit a personal injury law firm who offers to take on nursing home/care facility neglect and abuse cases. From what you describe here your mother has suffered most egregious neglect and even abuse at the facility.
The consultation with these kinds of attorneys are usually free and they charge nothing unless they take your case and win.
Even if they don't take your case they will start asking questions of the facility's administration and demanding they hand over charts and files. This is enough to get the facility and their caregivers to clean up there act and start taking better care of her.
Also, you never have to kiss up to any facility staff of bring them bribes and gifts. A great deal of money is getting paid over to the facility for your mother's care and that is enough.
What you do have to do is regularly check up on her and at random times. If you can't arrange for others to do so. This is what guarantees adequate care in a facility not bringing gifts and bribes to the employees. No facility wants to hear from a law office because they know why lawyers show up and it's always because of abuse and neglect.
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You need to trust that medi-cal will pay the bill and get her moved in.

You will end up having her in your home if you don't stop creating stops for her to be moved in.

Get her in and then deal with your questions. They won't be able to get paid beyond her assets and monthly SS or pension. They will get paid her share of costs with those and nobody will know what that is until she is fully approved for Medi-cal. However, all of her monthly income, except a small personal needs allowance, will go towards her care.

PS: you should file a complaint against the board and care home and it's owner. These are the lives of human beings this piece of trash is playing with. She needs to be prosecuted for her actions.
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Please don't take this wrong I am only trying to clarify some stuff.

First, if u paid for those tickets, it was unethical for the staff to except them. Same with gifts, they aren't suppose to except them. They can be fired for doing so. A luncheon for a thank you, no problem.

Now for the 90 days you are talking about. Where I live rehab and Skilled nursing are in the same building. So I am assuming Mom was sent to Rehab. Medicare pays up to 100 days if the person needs 100 days. The first 20 Medicare pays 100%. 21 to 100 is 50%. The patient either pays that 50% out of pocket or has a very good secondary insurance that pays all or part of the balance. If the patient in that 100 hits a plateau or fails to progress Medicare will ask for them to be discharged and stop paying. If they go to the full 100 days, thats all Medicare will pay. Then it has to be decided what happens with the patient. If 24/7 care is needed can they safely be discharged home with help? If not, then a decision needs to be made to place them in an Assisted Living or Long term care. If they can't pay privately for LTC, then Medicaid will need to be applied for to help cover their care. Where I live, patients are easily transferred from Rehab right into LTC at this point.

Now with your Mom, you could have applied for Medicaid while she was in the B&C. In my state, your given 90days to spend down, supply all info needed and find a place for Mom. Then its just a matter of timing that you transfer her from B&C to a LTC. With my Mom, I applied for Medicaid in April, she moved to LTC May 1st, paid May and June privately and July 1st Medicaid kicked in. Paying privately spent her down.

That 90 days you mentioned has nothing to do with placing her permanently. Medicare has nothing to do with LTC. They only pay for rehab. They may pay for some therapy. I know Mom got therapy when she was in the NH. Not sure if Medicaid would pay. I think at this point you need to get Mom placed first. Talk to the SW at the hospital and see if she/he can find you a NH that will take Mom with MediCal pending. Once she is placed, then ask about therapy.
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Silvas22 Sep 2021
Thank you for clarifying. My mom is located in CA near the central California area.

My mother was in the Hanford ICU in March, transfered to a southern Cali LTAC April 7th that was 4 hours away (3 weeks with trach, peg and vent; vent removed after 3 days arriving here), transferred then to subacute April 27th on other side of building(stayed for 3 months even though she should have been transferred to SNF after her trach was removed end of June but the subacute administration/therapy was the worst in helping her move and wouldn't give me answers/set goals to which we lost a ton of recovery time but started walking with assistance; during july I applied for medi cal long term), then she moved Acute rehab for 3 weeks on August 2nd (finally found a contact in subacute finance department that advocated for me and knew admitting doctor at Acute rehab. She was doing very well here and progressing but slowly, but because two person assist was required, we decided to try snf again. Acute Physicians assistant didn't like this and was very angry with us), then we were out of Medicare snf 90 days and she still was candidate for therapy since she was progressing at Acute and had order written by doctor but couldn't get back into snf so that's why we had to go with boarding care (transfered August 24th).

Tried boarding care with home health for a few weeks but the caretakers weren't equipped with taking care of her and would leave her in her wheelchair for 4 hours unchanged and she's incontinent which resulted in her back in ER on Monday with severe dehydration, UTI and spread to kidneys and altered cognitive status (she wouldn't open her eyes monday). The owner also admitted to only giving her water via her g tube once a day even though her discharge paperwork said 3x per day (she has g tube for hydration and supplemental feeding only if she doesn't eat 75% of meals orally). They accepted her in this boarding care because the woman that owns it is a RN and they have two caretakers in the house at all times to which we agreed to pay $5,200 private pay per month since it was supposed to be more hands on attention and we set goals to only keep her here for two months and then have home health help her get down to 1 person assist or none. There are only 5 patients total in this house. But with this new setback, I don't feel safe with her staying here.

We found a snf facility that's willing to take her but I'm trying to make sure if she's transfered, it's not just custodial care. The doctor and therapy team in the ER are recommending skilled nursing for sure so the order will be written but unsure if Medicare will approve it. The SNF we found called Friday and said they'll take us and know we are medi cal pending after they heard our horror story and said they want us to know there are people that care. So it's definitely the logistics here of how much therapy/skilled nursing is left and what will Medicare pay and then how much to pay with medi cal pending out of pocket cost or share of costs once officially approved. We have also reached out to our case worker at the hospital to see of they have a medi cal rep that can expedite our case but she said it's hard right now given the amount of covid cases in the central Valley. The central valley has the highest number of cases in CA right now and lowest vaccination rates. The Snf is in Fresno, CA.

We also have a private health policy that pays up to 300 per day for any necessary services like additional therapy, skilled nursing but have to file a claim in order to use it.
Your Mom needs too be in Skilled Nursing. If OKd for MediCal then place her. MediCal will pay their share of the cost of care and Moms SS and any pension will be need to pay her share of care.

I am surprised they thought family could do a two person assist when some facilities won't do it. Board and care was not a good fit. Maybe this will be. My Moms NH kept residents busy in the afternoon. If not some kind of activity going on, then a movie was shown.

Filing an appeal with Medicare probably won't work. She has shown in the days allotted (actually 100) that there is no improvement. They will not cover her because there is no progress and she has hit the days they pay. If its unsafe for her to be home then she is 24/7 care and should be in a nursing home.
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I don't think Medicare appeal would work, because their coverage for inpatient is for acute rehab care, not "custodial" maintenance. Your best bet is to have her go to the snf with MediCal. Medicare B can indeed cover therapy services for people in snf facilities, which would be billed as "outpatient" visits. A doctor would have to write the order and provide Medicare with adequate rationalization that the therapy services are medically necessary. Medicare no longer requires that therapy services are aimed at "improvement," as it used to be in the past. Maintaining function and managing chronic conditions are also covered.
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Your poor mom, and poor you! What a nightmare!

"Should I file an appeal with Medicare that says it's not safe for her to be home as she requires more hands on care to see if that can be approved? "

I would try to include a doctor's note or assessment from social services to medically support this claim. Wishing you future success as you continue to advocate for your mom. Blessings!
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