Help! Mom in limbo, hospital wanting to her to go but UHC Med Advantage says they won't pay since she can't bear weight. Thoughts?

You’ve gotten great advice regarding MA plans. They IMO r the devil.

Regarding Jimmo, I think it will be hard for you to get services using Jimmo as reason. Jimmo imo not really applicable to the situation.

For those unfamiliar w Jimmo, it’s a 2013 settlement of a class action Jimmo V. Sebelius (Katherine Sebelius was head of DHHS 2009-2014, so head of MediCARE). Jimmo, the plaintiff, was diabetic, legally blind, amputee and on MediCARE. She had been receiving in-home Health & out-patient therapy (OPT so skilled care by PT, OT, ST). MediCARE paid in the past but stopped as Medicare started to apply “improvement standard” for determining if Medicare would pay. Jimmo did not meet “improvement”. Jimmo was the lead plaintiff but the others were MS, ALS or in LTC due to preexisting conditions. I’m familiar w Jimmo, as I had a cousin with secondary polio on in-home OPT & the agency he used sent out Jimmo notifications.

Jimmo settlement requires Medicare to look beyond “improvement” alone for claim determination; & those who can benefit from skilled services for “maintenance or to prevent or slow decline or deterioration” are entitled to Medicare benefits.

The issue, imho, will be that for your mom there is no “maintenance” for her to stay at. All her issues are recent & significant. Sounds like she needs a rehab benefit to happen before can even be at maintenance. She needs rehab done to be able to get at a baseline. Terms of the Advantage plan is the issue, not Jimmo imo. I’d try to see if their plan has any rehab places that are in network (even if further away) & get her discharged from the hospital & transferred there as a patient for post hospitalization MediCARE rehab benefit. Rehab coverage is usually 20/21 days at 100% and then coverage at a copay only if progressing. Not improvement but progressing in rehab.

Jimmo seems best used if:
1. Have preexisting condition like MS, ALS, Parkinson’s, paralysis (like my cousins w polio) as they need “maintenance” or therapy “to slow or prevent decline”
2, getting skilled services in their home.
For residents in LTC NH, they can use Jimmo to have Medicare pay for PT to do “gait training” for walking or OT to do hand movement therapy to keep ability to grab & clench. Both would fall under “maintenance to slow decline”. My mom had gait training paid by Medicare 2-3 times wk in rehab area of NH till she finally had a fall & became bedfast. It’s not Medicare rehab coverage but Medicare coverage “to prevent further deterioration or preserve current capabilities”. To me, the issue will be that your mom does not have “current capabilities”…. She needs to get rehab started to see where she is for capabilities.

If that UHC MA plan won’t budge, I’d call CMS (centers for Medicare & Medicaid) to see if your folks can switch back to Original Medicare ASAP and before she is discharged from the hospital. The discharge planner at the hospital I would think has some experience in this.

Please realize that if Dad takes Mom home from the hospital, getting her into rehab or a NH later will be difficult. It just may be that a hard decision needs to be made that mom flat just needs 24/7 oversight for care and Dad cannot do this and there isn’t enough family to do all that would be needed all the time so it’s more about finding a LTC facility. I know this is can be hard to accept. You could ask for a needs assessment to be done as that provides on paper exactly what her care needs are. & you can evaluate if at all feasible for dad, you, etc at home.

If it’s leaning to LTC NH is best, I’d find one that accepts Medicaid. Mom may need to private pay a couple of months while dad / you find an CELA level of elder law atty to sort out their finances to get mom on the path for Medicaid should they not have the assets to pay for LTC for years. It’s a lot to deal with. It will be overwhelming but you can get thru this. Speak with fellow RNs to get thier viewpoints as well. Good luck.

Have you tried religiously owned SNFs?    They might be more flexible.

Our health care system does need a lot of work, but I'm not sure that inflexible insurance companies like the one your mother has are actually "broken", but rather are cheap, just plain cheap!  

I would in spare time research how to get back to straight Medicare, with a good supplemental plan  We've had BCBSM for years and never had a problem with multiple hospitalizations, SNF stays and home health care.   

If you don't get anywhere with the MD, PT, and/or social worker (probably also the discharge planner),go to the admin/exec suite and very professionally ask for assistance, on HOW to get PT for your mother.    Stand your ground.

Some hospitals in our area have their own PT facilities, either as part or extension of the hospital services, or in a related subsidiary or support organization.  I'm also thinking that a religious own rehab facility might extend their staff to help you find ways to pay for the rehab.  My experience was (a) it was the only rehab we've used that had REAL psychological staff full time, and that (b) they went out of their way to accommodate us, including me, when my father was there at the end of his life.

Last resort would be to bring some adverse publicity to the insurance company.   In my area, local newscasters love stories like these; it not only gets them publicity, but enhances their ability to reach out to the community for problem solving.

Can you imagine the effect on UHS of such negative publicity?   And if you purchased the coverage through an insurance agent, bring him/her into the picture, with firm advice that you'll never rely on them again.

And BTW, when you speak with the hospital staff, don't raise the issue of yes/no; take the position of HOW to get your mother help.  Don't let them weasel out of responsibility.  It would help if you could have a relative of friend accompany you, if not for moral support, to keep an eye on the staff and observe eye contact and unspoken responses.

My sister (psych nurse) taught me that.  In our first meeting with the rehab facility which wasn't performing up to par, she warned Dad and I to take seats at different angles so we could each observe the various staff participants, and see how they reacted to the issues we raised.

We had a different Medicare Advantage plan (Aetna) but ran into a similar problem when trying to get my spouse into short term rehab after hip fracture and hip replacement. We appealed twice, through the hospital's discharge planner, and were denied twice. He clearly could not come home with just me to take care of him and visits from pt, ot, and nurse. So, we decided to get him into a snf for rehab, pay privately, and pursue the appeal from there. the facility required us to prepay for a month! However, unlike the hospital they provided very thorough documentation based on their assesments of his need for inpt rehab. Within a couple of days the insurance company relented and covered his stay for a full 21 days. If you can afford private pay, you might try going this route, though be sure to have your mom go to a place that is in her plan's network.It's a gamble, but might be worth it.

I just had a conversation with my RN daughter concerning Medicare Advantages. She is a Unit manager for a Woundcare Unit. She called me and told me NOT to sign up with a MA. One thing seems her clients with MAs are paying more out of pocket and they are hard to work with.

Medicare contracts out with these people but you are under the rules of the MA. They are HMOs and PPOs meaning you must stay in their network to get the advantages. With straight Medicare you can go to any doctor who takes Medicare. My friend had a MA and needed surgery. A Medicare doctor was in walking distance from her house but he wasn't in her MA network. It was causing problems because she couldn't coordinate her surgery. It was open enrollment season so she switched back to straight Medicare.

Your parents maybe better going back to regular Medicare and paying for a secondary insurance and prescriptions. Your Office of Aging could help u decide what is best for your parents.

I'm so sorry that you're dealing with this dismaying dilemma. If your medical PoA is not yet activated, then when you are at the hospital, if possible and if your mom is able (assuming she doesn't have cognitive or memory impairment) have her assign you as her Medical Representative so that you can talk to her medical team without her having to be on the call or in the room. You can do it in a phone call. This is a HIPAA form that you usually get at the clinic but I'm assuming the hospitals have them on hand. They don't require any special notarization or witnessing, just your mom writing in your name (or more than one name) and she signs it.

Others on this forum can probably provide some sort of guidance for your other coverage questions.