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By John M. Bigler This month's article will focus on the Medicare program and the benefits it provides in the nursing home. Medicare is a Federal government program run by the Department of Health and Human Services. Most people are aware that if an individual is over 65 or receiving disability benefits, then they are eligible for Medicare. Unlike Medicaid, eligibility has nothing to do with your financial needs. Both the rich and poor have equal access to the Medicare program. Unlike Medicaid, the focus with Medicare is not eligibility for the program but, once having become eligible, to take advantage of the benefits that the program provides.
The patient must meet two criteria to be covered under Medicare: He/she must enter a nursing home within 30 days after a three day hospital stay and must require and receive skilled care. The Medicare regulations which define skilled care are very broad and include most of the treatments received in a nursing home. Skilled care includes the monitoring, assessment and observation of a person's total condition. Even though a doctor or physical therapist may not be treating a patient on a daily basis, he or she may be receiving skilled care if a nurse has to observe and monitor the condition daily. The Medicare regulations also give specific examples of the type of care that would automatically qualify as skilled care. These services include physical therapy five days a week, insulin injections, treatment for serious bed sores, intravenous injections, feeding tubes, catheters and the application of prescription dressings. However, other services may also qualify as skilled care. It is the aggregate level of care given the patient based on his or her needs that determines Medicare coverage.
The nursing home must give written notice to the family as to its decision whether Medicare will cover the patient's stay. It is a mistake not to appeal a non-coverage decision made by the nursing home, because it is not in the nursing home's best financial interest to make a determination that a patient is eligible for Medicare benefits. If the care is skilled, the nursing home must accept the payment from Medicare as full payment for the 100 day period (plus the co-insurance payment).
How does the patient appeal a non-coverage decision by the nursing home? First, the patient must request that Medicare itself make an initial determination of the coverage. This initial determination is made by a private insurance company hired by the Department of Health and Human Services to administer the Medicare program. If there is a denial, the next step is a Request for a Reconsideration. The insurance company will reconsider their initial decision. If the reconsideration decision affirms the initial denial, the next level of appeal is a hearing before an Administrative Law Judge. Because these judges are not bound by the previous decision, in most cases this will be the first real chance to present the case and to evaluate the care received by the patient pursuant to the correct legal standard for Medicare coverage. At the hearing, the patient's attorney has the opportunity to review the nursing home records and argue that the care provided meets the definition of skilled care. Usually an impartial medical expert will testify. The patient and/or family does not have to attend this hearing or testify. The success rate of appeals are very high. Most attorneys will accept these appeals on a contingency fee basis, meaning that they will be paid only if the claim is successful.
In summary, patients entering a nursing home should not be dissuaded from pursuing the coverage Congress intended they should have. The patient and family are often not aware that Medicare is available, or they may be discouraged by misinformation from pursuing these benefits. Seeking the help of an elder law attorney can often ensure that the most beneficial results will be obtained.
Reprinted with permission of the Suffolk Times © 2003
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Although Medicare does not provide the long term coverage that Medicaid does, it does provide for the first 100 days in a nursing home. The first twenty days are paid in full. The next 80 days have a coinsurance payment of $105.00 a day. Most people have Medigap insurance as part of their medical plan which will cover this deductible payment. Medicare will not provide a long term solution to the nursing home problem, but it can give the family the critical time in which to develop a long term plan. Also, as more and more people are entering nursing homes for short periods of rehabilitation, accessing Medicare coverage will avoid the need for making large transfers of assets simply to obtain Medicaid eligibility for a short term period.