Dad is out of days for Medicare but he is still in the hospital, so what now?

Your dad must be just worn out and your mom too. OK, now I see, the situation is that your dad has fully used his Medicare rehab 100 days maximum for this year 2012. Medicare rehab is just one part of overall Medicare and his Medicare for hospitalization for him still works. So if he has to have another hospital admission, Medicare is still there for him. It's only the rehab that is max'd out. My mom gets PT at her NH and I've gotten letters every autumn from CMS that she is within 90% of her Medicare annual limit (about $1,800) for PT so once that happens her PT gets billed to Medicaid.

Sounds like Dad can't go back home and there are limited assets and income so your dad will need to apply for Medicaid to pay for a NH that is a skilled nursing facility that does long term care (with some sort of rehab wing or service) that takes residents "Medicaid Pending". If they do and your dad qualifies both financially and medically for Medicaid, then the payment to the NH will be whatever your dad's monthly income is LESS your mom's monthly maintenance since she is the still living at home community spouse (i'm assuming she doesn't work). If a NH takes Medicaid pending applications, they are used to the long wait for the state to start to pay but your mom will have to pay whatever is dad's anticipated share each month. Medicaid Pending is critical if you don't have the ability to private pay.

There are a whole bunch of issues that make Medicaid with a community spouse kinda complicated - my mom and my MIL were widows so I didn't have to deal with that aspect. I really think you should get your parents financials together including the details on their assets like value on home and go and see an elder care attorney to perhaps restructure things. There are things that you just don't think about that could make a difference....like say they have a small 20K life insurance policy that names each other as the beneficiary (most couples routinely do this) but say your dad is on Medicaid and your mom still living at home and an accident happens and mom dies and then your dad now has gotten the insurance 20K and gets kicked off of Medicaid and has to spend down the 20K at the NH before he can get back on. What you might want to do instead is change the beneficiary's of the policy to a special needs trust for your dad or a family trust. The trust is it's own entity (it's own legal being) and your dad's Medicaid status doesn't change but he can use the $ in the trust to pay for things that Medicaid doesn't or does minimally (like dental). Also some states have the community spouse maintenance set low and if they still have a mortgage, the spouse sometimes has to go to court to have the maintenance increased to be able to pay the mortgage and overall living expenses. Yep I know it can seem crazy complicated but every day I am thankful that we have Medicare and Medicaid. Also keep in mind that if the first Medicaid paid NH just doesn't work out for your dad whatever reasons, you can move him to another one that accepts Medicaid and stay within the Medicaid system. Good luck.

igloo 572
dad has been in rehab facilities, NH, and hospitals for the past six months. He had already used up his one hundred days doing therapy at a NH. He was home for three weeks and than fell and broke his femur so he went back to the hospital. I am pretty sure that they will not release my dad to go home and that he needs to do rehab, most likely at a NH, again.
If we do have to go by way of Medicaid, and it takes that long, than where does my dad go? I assume that since he has used up his days already, that even though his broken leg is a new "symptom" that it still doesn't come under Medicare?

Paul - this is all alot to deal with and in short order. Now first, who said that he is "out of days for Medicare"? It's important that you try to understand what Medicare does and what Medicaid does and how they dovetail. This site has many good articles on this so go up to the dropdown list to read some of them.

So is dad still in the hospital OR is it that he has been transferred from being a hospital patient to a rehab patient.?? The rehab can be at the hospital, a seperate rehab hospital/facility or a NH that has a rehab unit. And is it the situation where dad is in rehab for about 3 weeks?? Then he is likely meeting the maximum days for a normal Medicare paid rehab period. Most NH admissions come from a hospital discharge of a patient to rehab within a NH and the patient doesn't rehab enough to go back to their home to live so they then become a resident of the NH. If an individual covered by MediCARE is discharge from a hospital to a nursing home for continued care (rehabilitation) after an inpatient stay of at least 3 days at a hospital, Medicare will cover 100% of the first 20 days and MAY pay up to 100 days, subject to a co-payment by the patient of $141.50 per day for days 21 to 100 (for 2011). Medicare does not pay for the many months/years that some people reside in a NH for long-term custodial care. In general, Medicare is limited to short-term acute care. It sounds like this is what is going on with your dad.

But this MediCARE paid period of time in the NH is when you need to get the documents together to apply for MedicAID IF Medicaid is how your family is going to pay for your dad's NH stay and he is not going back home.

MedicAID is not automatic. Medicaid rules determined by each state & are state specific even though it is a federal & state program. Medicaid is needs-based.
Your parents are expected to spend assets first and foremost before the state will pay. There are things you can do to reduce assets but these need to be done by someone qualified to do this that will pass your state's review of your dad's Medicaid application. An certified elder law attorney is best. One of the real challenges you all will have is the whole "community spouse" issue as your mom is still living in their home and she will have to have income in order for her to remain in the community. The home is an exempt asset from Medicaid - there is no signing over their house as she lives in it. Their assets are exempt to a certain level (most states have this at 109K for the community spouse's asset limit) to enable your mom to remain living in the community. It can get overwhelming to deal with under the best of situations, that's why having an elder care attorney work with you in all this can really be a godsend especially if your folks have not done any legal like DPOA, MPOA's, wills etc.

Whether you pay out of pocket is dependent on the NH. Many do not take Medicaid at all, some do not take long term care insurance. I'd suggest that you need to have a definite spare-no-details talk with the social worker at the facility to see what they do and whether your dad is a good fit for the facility. Then you deal with admissions at the facility. My mom's NH admissions gave me a 1 page list of the documents needed to accompany the application (my MIL's NH gave my BIL a 2 page list, this was in the same state too); then I took those documents to meet with billing to do the Medicaid application - it was over 100 pages of documentation too which was due to having to copy each and every page of my mom's old school lenghtly term life insurance and burial policies; then the NH submitted my mom's application to the NH state caseworker along with their NH bill. It was about a 5 mo process to go through for my mom and about 10 mos for my MIL. We did not have to private pay anything because her NH accepted new residents "Medicaid Pending". This is important as not all NH do Medicaid Pending. Again you need to ask clearly what the NH does or does not accept for payment. Whomever is the DPOA might be the best one to sign any documents as your mom may not be in the best frame of mind AND whatever you do sign everything as "Jane Smith as DPOA for John Smith". Good luck and take a deep breath and keep a sense of humor.