My Mom has Medicare A & B, plus Long Term care Insurance she has paid into 25 years. The nursing home just called and said she is no longer considered skilled care after rehab for 22 days and will have to go private pay; they had initially said Medicare would pay up until 100 days. So they are pushing me to make a decision about her nursing home care and say I have to appeal the decision to not be skilled and I have to make this decision within a few days. I am worried that they might just be after our money.
Nursing homes are often reluctant to keep billing Medicare, because they think Medicare coverage depends on the beneficiary’s restoration potential; but the standard is whether skilled care is required.
Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities. The nursing home patient who needs these skilled services should still be covered by Medicare.
The February 16, 2017 statement by Centers for Medicare & Medicaid Services (CMS) says: "Skilled nursing services would be covered where such skilled nursing services are necessary to maintain the patient's current condition or prevent or slow further deterioration so long as the beneficiary requires skilled care for the services to be safely and effectively provided."
Medicare has posted plenty of material for you to read.
https://www.medicare.gov/coverage/skilled-nursing-facility-care.html
But the most efficient way to learn whether your mom needs skilled care is to talk with an advocate in your state who can give you an objective view. It's important to coordinate Medicare eligibility with other resources like LTC Insurance.
I am assuming that your Mom was in the hospital and was transferred to the nursing home for skilled care/rehab with physical therapy and occupational therapy. As Barb stated, Medicare will pay 80% of days 21-100 IF (and only if) mom is progressing in therapy.
If your Mom is not progressing in therapy (i.e. she cannot walk a greater distance today than she did yesterday or she cannot perform her own ADLs more independently than yesterday) or if your Mom refuses to participate in therapy for 3 days, then therapy is discontinued and her status changes from skilled care to long term care if she is unable to go home or to Assisted Living.
If I read your profile answers correctly, you and your Mom were living together. Do you want your Mom to return home or do you want her to go to an Assisted Living facility (many ALs calculates monthly fees based on a points system according to how much help your Mom needs).
If your Mom needs someone to help her bath, get dressed, take her to the toilet, supervising her as she walks with a cane or walker or if she uses a wheelchair, then a long term care facility might be a better fit for her.
You need to look at the long term care insurance policy and see what it pays for and how long it pays (most pay for 1825 days or 5 years.) Does it pay for Assisted Living facilities (rare) or just Long Term Care/nursing home facilities? If the insurance only pays for LTC/nursing home facility care, and your Mom needs physical assistance with her ADLs every day, then your Mom would probably be better off in the long term care facility.
If your Mom becomes a resident of the long term care/nursing home, you need to sit down with the LTC facility's Social Services Dept. and Business Office to determine how much the Long Term Care Insurance will pay every month and how much you are going to have to pay every month.
Then you need to contact the Long Term Care Insurance Company and tell them that your Mom is in _______ facility and that you want to activate her long Term Care Insurance Policy. {Who is your Mom's Financial POA and her POA-HealthCare--I assume that it is you.} It will take about 3-4 months before the insurance payments are sent to your Mom (or you if you are POA) and the "deductible period" has been met which means that your Mom needs to have been at the nursing home for 90 days or so before the insurance will begin paying for your Mom's care. Since your Mom has only been in the facility for 22 days, then she will have to private pay for her care (approximately 70+ days) until she meets the LTC Insurance requirements for number of days in the facility (90-120 days)
LTC Insurance pays for the PREVIOUS MONTH'S expenses. So at first, you will have to pay for approximately 3-5 months of care. {I had to pay $10,000+ for 2-3+ months as my Mom had met the 90 day qualification when her LTC Insurance was activated.} When the LTC Insurance checks come, either your Mom or her POA will have to sign them and deposit them into her checking account.
I am not sure about the payment situation for Assisted Living as my Mom went from home to the hospital to the nursing home. Maybe someone else could answer any questions that you have if you are planning to move your Mom to Assisted Living instead of having her stay at the LTC/nursing home facility.
In the LTC/nursing home facility:
Every 3 months, an Resident Assessment (required by Medicare and Medicaid for all M / M certified nursing homes) and a Care Plan will be completed by Social Service, Nursing, Dietary, Activities and Therapy (if your Mom had any).
Then there should be a Care Plan Meeting that your Mom and any of her family members or her POA can attend and are often encouraged to attend.
Based on the amount of help that your Mom needs with her ADLs, supervision needed due to behaviors, medications and treatments; your Mom will be assigned a Care Level. The cost of your Mom's care will be based on which Care Level she is given. Each state has a different formula for calculating Care Levels and how much each level cost.
Is that clear as MUD?!? C:--)
Medicare will pay 80% of days 21-100 IF (and only if) mom is progressing in therapy.
If she is not, and she cannot be discharged home or to Assisted Living, then they (or you) are looking to shift her to Long Term Care.
Does the NH know that she has LTC insurance? YOu want to sit down with the business office AND the SW at the NH/Rehab and hash this payment issue out.