Can Medicare deny my grandmother coverage for being uncooperative at the nursing home?

Medicare part B is supplemental insurance that you pay for yourself. It's not automatic, every fall seniors get many, many offers from different insurance companies. Different prices and different coverage also offers for part D (to cover medicines).

Unfortunately, I have lots of recent experience with Medicare and Medicaid issues... I won't go into Medicaid here - TMI! but will cover Medicare... Medicare Part A is what pays in-hospital charges and then UP TO 100 days following discharge in a skilled nursing/rehab facility. Med Part A is available free to anyone who has contributed to SS when working. (My Mom did not have Medicare Part B, which is deducted from SS, and helps with expenses other than the actual hospital charges and facility/rehab charges) but she did automatically have Part A when she fell and broke her hip & wrist. 

When in the skilled nursing/rehab facility covered by Part A, the first 20 days are covered completely. After that, the last available 80 days are covered with a co-pay of ~ $157.00/day (Oregon). Her co-pay was out of pocket - I don't know whether they would have been covered if she had M. Part B? 

The big thing to know here is that this 100 day coverage is NOT automatic, but has to be proven beneficial (progress made in therapy) over and over to Medicare! They require periodic reports from the rehab facility, and when the facility anticipates Medicare will not approve further charges, the facility Social Services department decides on a discharge date! This is calculated by the facility from their understanding of the rules and experience with past patients. If you disagree (for example, my Mom's therapist said she was making good progress, but the Social Services office gave me a discharge notice because they claimed she wasn't making progress...) you can and should make a formal appeal to Medicare. 

The facility should give you paperwork along with their discharge notice explaining your rights under Medicare to appeal, and how to do that. It's easy! Just call Medicare and file the appeal. From that point, Medicare has medical experts review the medical/therapy file and give a decision within 24-48 hours of the filing. Once they make their decision, you have until 12 noon of the day following that decision to move the patient. If the patient stays beyond that deadline, any further charges will be billed to the patient. I ended up filing two appeals, which were both upheld, and my Mom ended up using 94 of the 100 available days (which the facility had never seen before!). Interesting fact: Once the patient leaves the skilled nursing/rehab facility, if they go home, or to assisted living, or to a group-type private home, AND are not admitted to the hospital or have a medical issue requiring use of Medicare for 30 days, the Part A/100 days starts over! 

For reasons I don't understand, this is not the case if they are in a Nursing Home. If in a nursing home, costs have to either be covered by private pay, or the resident has to apply and be approved for Medicaid. Medicare does not cover nursing home residency charges! 

All of this is according to the State of Oregon, and since different states can impose somewhat different rules, I don't know how different it might be elsewhere, but I'm guessing most of this is universal. (BTW, the option to appeal to Medicare for a "stay of discharge" is also available if the person is actually in the hospital and the staff/doctor deems them ready for discharge, but you believe they are legitimately not ready.I did that successfully too! The doctor’s decision to approve discharge was made without all the facts from the nursing staff.)

There are a lot of uncooperative people in nursing homes especially memory care!! The doctors and families usually try to work things out and figure out what needs to be done and how to work with her. As long as she qualifies to be in a nursing home medicare will pay on the bills! Social workers don't always know what they 're talking about--I just had a bad experience with one. If necessary talk to Social Security or maybe an elder lawyer.---so you'll know what's what.

Hi there, Medicare only covers 100 days of skilled nursing care. Generally this is designed for people who are recovering from an injury or illness and are expected to make a full recovery and then return to caring for themselves. It is not designed to be long term care for people who have a deteriorating health condition that will lead to long term care. For short term care in a skilled nursing facility, it is quite rare to see Medicare deny claims, and if they do, you can appeal it with a letter from her doctor explaining that her behavior is a symptom of her illness. In any event, since Medicare will not cover nursing home stays long term, you should be planning for how to pay for this privately, whether you use saving or apply for Medicaid to see if she can qualify for a state-provided one based on low income.

I have nothing to add except good luck with your meeting. Ask the Nursing home if they have a social worker you can meet with.

I wouldn't think so, but it really wouldn't make sense to cover something if she's not going to cooperate either. I mean think of it this way:

Let's say you need therapy but refused it. It wouldn't make sense to bill insurance for treatment you refused, they're only billed if you actually accept the treatment. The same thing goes for treatments in the nursing home, insurance is only billed for what the patient agrees to. Now, if the patient is under guardianship, things would be a whole lot different because the guardian will have the final say over what the ward gets and what they don't

It is such a shame that some people who post don't understand the difference between Medicare and Medicaid. And Medicaid that covers just Healthcare and Medicaid that pays for NH care. Understanding would help so much when getting thru the maze making decisions. Hard to make decisions when you don't know the information. Hope they had a Social Worker who can explain it.

JM - how did the meeting go?
Is there a new plan going forward for gran?

Medicare does not cover nursing home stays, except for rehab when the rehab center happens to be in a nursing home building. As BB says, they do not pay for rehab if the patient is unable or unwilling to benefit from it.

Her lack of cooperation is not a symptom of what the rehab is trying to treat ... it may be a symptom of her dementia. But she is not there to treat her dementia. If/when she is admitted to a nursing home or memory care facility Medicare will not cover that at all. If she cannot pay for her residential care herself, she should apply for Medicaid.

I think I'm saying the same thing BB said. Maybe hearing it a couple different ways will help it make sense.

Is your grandmother actually in the NH as part of rehab after a hospitalization?

In that case, Medicare will only cover her stay as long as she is progressing in therapies, such as OT, PT and speech. If she is not progressing, or not cooperative, the coverage ends.

Now, possible reasons she's not cooperating? Start with pain. (My mom had an undiagnosed broken hip, didn't show up on first xray. Dementia patients often can't tell you that they are in pain. If she's not bearing weight, or if she's scrunching up her face, INSIST that she be examined for compression fractures in her spine and for pelvic/hip fractures. DON'T take no for an answer.)

Vascular dementia often comes with paranoia; is your grandmother USUALLY a cooperative person, or is she often uncooperative?

Is there a geriatric psychiatrist who can come in to see her? Sometimes psych meds help agitation and anxiety in dementia.

Is your plan for grandma to stay at the NH for long term care? Have you applied for Medicaid (not Medicare, which does NOT play for long term care past the rehab stage) for her?