Skilled Nursing to Hospice back to SN - Who Pays?

my mom is in a nursing home she broke her hip, she was in the hospital from 05/09 - 05/13, and then in skilled nursing from 05/15 -06/06 she has part a and b medicare will her copay be less?

Igloo - So she did end up getting stuck with bills for PT, OT, etc.? I haven't heard of the Medicare rehab 21++ days -- I hate getting told after that fact - things like, "well, because you went through this step and that step, you qualified initially, but now your coverage changed so don't qualfiy so you have to pay yourself." This whole nursing home thing is totally new to me. Too many surprises. The nursing home wants us to "take responsibility" to know her insurance benefits - but we don't always even know what to ask!

Deb - I'm guessing this is for me? Between Medicaid and Medicare all gets paid but whatever is their negotiated rate (which is usually less than what BCBS would pay, which is why providers were less than happy). And they can't charge her for whatever is the differential between the billed at rate and the insurer paid rate. In many ways, Medicare/Medicaid combo is great as there will be no huge medical or hospitalization bills to ever face, although not always providers for many.

Premiums refunded but co-pay was low (less than Medicare copay from SS). Her's is/was a federal BCBS plan so either way it's fed $$. Medicaid would be cheaper as they pay less for the same procedure.

NH Medicaid has to go retro to day 1 so that they can pay for room & board @ the NH from day 1. Neither BCBS or Medicare pays for the long-term NH r&b charges, that's only by Medicaid, or private pay or LTC. My mom went to NH from IL so she wasn't admitted on the Medicare paid "rehab" 21++ days situation which is how most go into NH.

That makes NO sense. I thought commercial coverage was supposed to trump government coverage - at least in most cases (although not all). I hope she at least got her Blue Cross premiums refunded. If she's not getting benefits, then there shouldn't be any premiums paid. And why would Medicaid have to go retroactive to day 1 of the nursing home admit? Seems like it should start when commercial eligibility ends. That would save the government money - which, again, I thought was the priority with insurance.

Did Medicaid pay for the PT, OT, etc? (I certainly hope they did!)

Once hated - my mom had/has BCBS. Dad was federal employee and it is a super duper high option federal BCBS. When mom went into the NH, she was still covered by BCBS. But - a big BUT too - once she was approved for Medicaid, her BCBS got suspended. Not cancelled but suspended. Medicaid is now either her secondary or primary to Medicare (which seems to depend on the code).

For the period of 5 -6 mos while she was Medicaid Pending, BCBS covered lots of stuff at the NH, like PT and OT and equipment and ambulance transfers. But once she was on Medicaid and Medicaid was retroactive to Day 1 of NH admission, BCBS did a clawback on all the $$ it paid to the NH and any providers @ the NH from Day 1. A couple of the providers were pissy about it as BCBS pays a much much higher rate than Medicaid.

Since her husband was a vet check on Vet.aid and assistance which many people don't know even spouse of vet could get $.

How great! I never did check with FIL's secondary, Blue Cross/Blue Shield of Michigan. I am going to call them and find out if they would have covered the nursing home or hospital coast during hospice. Good to know for the future for MIL even if I can't get the reimbursement.

Thanks so much for the replies! It's been unbelievably difficult to get information on this. My mother-in-law is actually one of a very few Americans who doesn't qualify for Medicare without paying for it (Part B AND part A). Her late husband had a Civil Service job and had the option of Social Security or a separate retirement plan (there was a short period of time when this was an option) and he chose the retirement plan. So she doesn't qualify as his dependent. She has worked part-time but not enough quarters to qualify for Medicare under her own SSN. Her insurance, therefore, is the Rural Carriers Benefit Plan (Coventry) with Champva as secondary (since her late husband was a fully disabled Korean War veteran). My sister-in-law e-mailed me this morning saying she'd talked to Coventry and was told they DO pay for room and board while in hospice. That makes this a LOT easier! The nursing home didn't precert the stay during hospice, so they'll have to request a review to see if they can get a backdated precert. If Coventry won't backdate, then the nursing home has to eat the charges since it was their contractual obligation to obtain the precert. (The nursing home does contract with Coventry.) SIL and I both told the nursing home - more than once - that MIL is NOT on Medicare. However, it sounds like they handled their billing as though she is.

What a mess! Hopefully the nursing home gets paid and we're done (with that bill, anyway). Thanks for the advice on negotiating a discount, and also on a potential 30-day notice. We'll keed those in mind. I'll also let my SIL know to be careful to sign as POA. I think she's doing that. Actually, I think my MIL is signing for herself most of the time.

When my FIL was in hospice at his SNF, we still had to pay his usual rate. We could have taken him home was an option hospice offered. I did wonder how much it would have cost for hospice in the hospital which was also offered.

Another thing, if Medicare paid for hospice, your mom should get a statement from CMS (Center for Medicare & Medicaid) detailing the dates & procedure & amount paid and disallowed. So you might be on the look-out for that piece of mail as the insurers might request it to see what was paid and how it was coded to see if anything could be covered by LTC policy. Sometimes Medicare will pay 30% - 80% of a procedure and the provider depending on their policy, MAY OR MAY NOT send your mom a bill for the difference. So say a blood draw charge is $ 100 & Medicare pays $ 32.00 for a draw, then a lab (like Quest) may send you a bill for $ 68.00 if she is private pay. My point is that the NH room & board bill may not be the only bills you all get and it could take 60 days for these bills to get sent. LTC insurance is like having it all private pay so there is no Medicaid discounting or zeroing out. Good luck.

Was any of her hospice billed to Medicare? It could be that her hospice was billed to Medicare.

Hospice is a 100% Medicare covered service. But Medicare does NOT pay for any of the room & board costs related to being in hospice @ a NH. That either is private pay, Medicaid or long term care insurance. What can happen with LTC insurance is that the policy is worded such that hospice related costs are not covered as Medicare is the primary for hospice. Hospice since it is not skilled nursing is not covered under the LTC policy which requires skilled nursing.

You need to look at the NH contract that was signed off on to see what their appeal process is and follow that. BUT really you need to contact in writing her insurers to see what is included and paid for in her LTC policy.

Now if any of you signed her into the NH and signed off as being financially responsible by signing her in & under their own signature (and not as Jane Smith as DPOA for Ann Jones), then the NH will eventually come to them to pay the bill.
If that was your SIL, then she will be the one the NH comes after. If it was you or your hubby, then you get it. What happens after maybe 4 weeks if family seems to have done nothing but ignore this, is that a "30 Day Notice" will be sent to whomever signed her in. This is a total panic situation to be in, so you really want to avoid this. If she is back in skilled nursing and she & you all like the place and her LTC is back up and paying in full, then I'd negotiate with the NH to reduce the 2 weeks costs by 50% as she is going to be a good customer over time.

You know some NH will not take LTC insurance, my mom's NH won't - only does private pay and Medicaid and Medicare. Even though the LTC insurance will pay a much somewhat higher rate than Medicaid, they won't do it because the reporting required by the insurer from the NH is too much to be worth it and there are plenty of Medicaid patients out there to fill a bed when there is one available.