I just received a letter from a Medicare and Medicaid service that a 3 week time span Dad was at the NH won't be covered. Advice?

Igloo is on the ball! $45 was all my dad had to pay the NH, I knew about the personal allowance and it had nothing to do with that. Medicaid could not take my dads monthly income because my mother needed it to live on. They did not have much at all, no savings, small chkg. acct., thats it. Therefore, she was allowed to keep what he made except $45.

igloo you may be right. That's why I recommended a lawyer look it over.

Pam - I think the $ 45 a month could totally make sense due to the community spouse. Will depend on the state though. Like the CSRA for Texas is $ 2,931. So if this was a TX Medicaid situation, & if dad got as income $ 3,066.00 a month, then his co-pay or his SOC to the NH would just be $ 45 a month and he also would have $ 60 a month for his personal needs allowance. All the rest would be diverted to the community spouse for her CSRA of $ 2,931 if she applied and qualified.

It doesn't sound quite right that he only had to pay $45 a month. That small amount sounds more like his personal needs allowance. Maybe you need to have a lawyer read the forms you signed and have him interpret them. Usually the NH will take his entire check unless his wife had a "community spouse allowance" based on her expenses. She would only get the portion of his check permitted for allowance.

OK under Medicaid rules, if the deceased has any assets after death, then the state can try to get a "recovery" of the costs the state spend on their care. MERP - Medicaid Estate Recovery Program is charged to do this & all states have to have some MERP in place.

Now in order to go onto Medicaid in the first place you have to be "at-need" or basically impoverished. Most on Medicaid have nothing so nothing MERP can go after. Now if they are married, then the surviving spouse may have assets (your mom's 9K in savings) and those are protected from MERP. Really the only asset they could still have is their home, so then the home can have a MERP claim or lien placed on it. MERP sends out letters to whomever is on file for Medicaid as their contact. Letter is not warm & fuzzy but more like "we're sorry for the death, the state paid $ 68,789.34 through Medicaid and we want to get it back". There will be a response form to fill out that has to be done if you want to file any exclusions, exemptions, hardships. Being a surviving spouse is a full exemption in & of itself. So your mom will qualify for that one. Now some states do seem to have their Medicaid program keyed in to recognize that there is a surviving spouse so those in those states never get a letter. But your state may send a letter (may go to mom or maybe to you if your the contact on file) anyways, so if you all get one you have to fill it out and get it back to the state to close the MERP file. Now some states have outsourced MERP and those are more like a debt collection process……again not warm & fuzzy. They get a % of the recovery too, about 15% for most contracts.

Igloo, sorry I just remembered, what is a MERP letter??

Igloo572, thank you very much. We are on the same page here, you wrote exactly what happened last year. The billing dept. at the NH told me Medicaid would kick in after Medicare stopped which was exactly 21 days. I will call the NH billing dept. and in my letter it also stated that the NH would also get a letter. This company is called Maximus Federal Services. Thanks for your input!

jd - geez really if there was an odd twist to Medicare & Medicaid you & your family has gotten it! You have the patience of saint!

OK so dad was on Medicare and then you applied to Medicaid for him when it became evident that he was going to need to stay in the NH, that's the situation isn't it?? And dad moved to the NH after being hospitalized, correct??? Dad got accepted by Medicaid, correct?

If this is the situation, then what is likely going on is that the NH billed Medicare for his room & board & medical services beyond the initial post-hospitalization "rehab" benefit that Medicare routinely pays for. The "rehab" stay that is OK 100% for Medicare is usually 21 days but can go another week or two. It could - in theory - go for 100 days with a co-pay, but I have never known of anyone who got that length of a rehab benefit who was elderly. But Medicare will only pay for his stay under the "rehab" benefit if he is progressing in his rehab. Since dad didn't, Medicare will not pay. He would have gotten discharged from "rehab". Then either his stay @ the NH needs to get paid by private pay or Medicaid. If he applied to Medicaid, then their coverage should kick in the day after Medicare stopped. I would ask the billing dept @ the NH if they billed Medicaid the minute Medicare stopped.

Medicare is totally federal with payment coming from the feds based on whatever set rates for services provided. But meanwhile Medicaid is administered by the states and they tend to be slower payment. Medicaid reimbursement rates are much much lower than Medicare too. So the NH will tend to bill Medicare first & foremost as they make a lot more $$ from Medicare. Anyways, I bet what is happening is that Medicaid reimbursement to the NH has not caught up with paying for dad. Again check with NH billing dept as to when they billed Medicaid for dad's room & board stay. I would send it over as a registered letter after you have called them too.

If dad qualified & was on Medicaid and dad did the required co-pay or his "SOC" - which sound like the $ 45.00 a month you paid, then dad was kosher for Medicaid. Mom should not have any health care bills to pay (assuming the providers all accept Medicaid & Medicare) nor should mom have any MERP claim or lien to deal with (as she is the surviving spouse so there is no estate recovery action). If mom gets a MERP letter, you need to respond to it in pretty short order too - some states have the fact that there is a surviving spouse keyed into their data base so no MERP letter goes out and other states send the MERP letter always. So try to be on the look-out for it just in case mom is too overwhelmed to notice it. Now dad may have gotten some PT or OT services in the NH than came from on outside vendor (that doesn't bill through the NH). If that is the case, they too will get the letter from Medicare that the payment they may have been expecting from Medicare will not be coming, they too should bill Medicaid to get paid. Good luck.

You would need to provide more information and I agree with Kathy1 who says go to whomever is the SHIP volunteer in your area (Senior Center, Center on Aging, they have different names--as does SHIP)

For example, who was the "medicare and medicaid service company?" Do you mean the insurance company that handles Medicare in your state? You say "that a 3 week time span that my father was at the NH will not be covered under medicare." Do you mean the other 7 weeks were? By whom? Medicare should not be paying for any of the services if it was not skilled nursing. Ask to see the "Advance Beneficiary Notice" you signed (why not your mother? Did you have his power of attorney?) and take it to the SHIP counselor.

And most important, don't "assume anything." Good luck.

Appeal the decision. Talk to the medicare ombudsman. If you contact your county council on aging, they will give you needed advice. Also write a letter to your two senators, and your congressman asking for an explanation why it was denied,and help you can't afford this. They have people whose job is to itercede with the federal agencies. Good luck

jd, I'm not sure. When my mom passed away, the hospital and the ambulance company sent us mom's unpaid bills that Medicare did not cover. When I tried to bring the Medicare notice and her billings to the other insurance, that insurance refused to take anything from me. They asked me if I was mom's Executor. No. Then they asked if I had a document from the court stating that I can handle mom's stuff, I said No. But since she's dead, there's no HIPAA violation. They told me that if I don't have any legal documents, they are not required to take those unpaid bills.

I did a quick search on the Advance Beneficiary Notice for Medicare. Have you read this already?
http://www.medicare.gov/claims-and-appeals/medicare-rights/abn/advance-notice-of-noncoverage.html

Hopefully someone here will be able to help you with an answer from their experience.