Medicare Advantage plans & inpatient rehab - Page 7

151949 · ‎03-09-2010

@Nicknack wrote:
@BalletBabe wrote:
@Carmie wrote:
@BalletBabe wrote:
@Carmie wrote:
@Kachina624 wrote:
@conlt wrote:
I have said it many times on these boards and people always argue with me but the Medicare Advantage Plans do not pay just like Medicare. I have worked in health care specifically with the elderly as a RN executive in home care. My business is a Medicare business. I think the advantage plans are fine for a healthy individual who wants to save money on prescriptions however, I have seen many times when they don't want to take care of someone who needs more intensive care. When Medicare rolls around for me I am taking straight Medicare, a supplement to cover the other 20% and then a part D drug plan. My 91 year old mother is on this and she never pays a dime for anything other than her insurance. Please be careful with the Medicare Advantage plans, you never know when a critical illness is going to happen and you need good coverage.
@conlt I don't know what you're talking about because my plan has no maximum lifetime limit. Mine also has a part D drug plan. It covers everything I would ever need. These plans are not all the same.
I know what she is talking about. I worked in Health a Insurance for over 25 years, and I agree with Halo117.

You might be surprised what your Advantage plan does not cover at 100%. You won't know until you need that benefit.

One of my family members is in the hospital right now. She has an Advantage plan that covers just about everything. She pays $90 a month for it.

I just checked into her benefits today. She has a $200 deductible for the first through the 7th day of an inpatient admission. She has been there four days already and will probably owe $1400 at least for seven days when she is discharged.

She used to have Traditional Medicare and Plan F which paid 100% of all her inpatient admissions. She dropped that insurance on Jan. 1. I have no idea where she will get the money to pay this bill. She is living on $1200 a month from SS.
You can set up a payment plan with the hospital. They have to take what she can give. Do not give them a charge card or a debit card. They try to get it out of you while you are there. DON'T GIVE IT TO THEM.
I know what you are saying is true. The hospital won't bill her until after the claim is processed, so no CC on file.

I just don't have a clue where the extra money for this bill will come from. Her monthly bills for her RX drugs are very high. Hundreds a month because she takes so many. 17 pills in the am and 12 in the pm. She also has a mortgage and pays her utilitiy bills. My brother pays her RE taxes and I help her with her grocery bills and other expenses. Her home is in need of repair. My sons can fix things for her, but things need replaced and updated, not fixed.

There is no money left at the end of the month. Her clothing is getting worn out. Her health is not good and mentally, she isn't always "with it". Sometimes she will spend money she can't afford to or give it to the small children in the family as a gift for a birthday or holiday and her bills suffer.

She used to work in finance, so this is unlike her.

I have been trying to get the family together for a meeting, but they keep resisting.
I would suggest she sell her house and move to a senior apartment that has an income based rent. Something small. She lived with me for 9 months after a serious hip injury and back surgery, but begged to go home. So home she went home last April.

I am her POA, but don't want to make or force her do anything. I want her to except change and move on. She keeps saying, "but I want to live here in my home." Well, she can't afford to.

Lately she has been sick, hence the hospitalization. Her kitchen was so dirty and gross when I went to check on her, that I almost fell over from the stink. She was too sick to clean or do dishes.

She has always been clean crazy and used to re do everything I did because it was never clean enough for her. I just spent a whole day cleaning her home, scrubbing and deep cleaning because it was so bad.

She was sick, but didn't tell anyone how bad she was. She called me for an unrelated issue and I knew something was wrong right away. I took her to the ER still in her nightgown, slippers and robe and she was admitted.

I don't think she should live alone anymore, but I don't know what to do for her. I am going to call the office for the aging on Monday. I hope they can help or offer suggestions.

Sorry for the long rant. I just needed to vent..
She definitly needs to get off the Advantage plan. That plan is for people that are healthy and don't need meds that are expensive. You might want to have her apply for Medicaid, especially if she cannot afford a supplemental. There are also pland to help patients with low income to get help with meds. Make some phone calls! Good Luck! It is a shame that they do this to the older generation.
She may be able to get on a Medicaid plan now, but she couldn't go to Plan F. You can't switch from an Advantage plan once you're already on it. At least that's the way I read it.

That would be incorrect information. You can't switch from an advantage plan to regular medicare while you are being treated for something -- for instance if you are on an advantage plan and you get diagnosed with cancer - you can't just switch to a plan F now so they pay all your bills. You would have to stay on the advantage plan until you are through the treatments for your cancer, but then you could switch if you want to.If you aren't being treated for any major illness you could switch during the sign up period in the fall if you want to.

bebe777 · ‎12-10-2012

@Carmie wrote:
Every Advantage Plan is different with a different set of benefits. You friend needs to read her benefit booklet or call CS at the insurance company.

I can tell you from experience that MOST, But not all Advantage plans cover 20 days of inpatient rehab after a three day hospital stay.

Once you are hospital and rehab free for 60 or 90 days depending on your policy, you get another 20 days.

Every time someone asks for Medicare information on this forum, I always tell them to be sure they have at least 100 days of IP rehab at a skilled nursing facility ( SNF)

This benefit is so important and often overlooked. Traditional Medicare covers the first 20 days at 100%. After that you have a large copay from day 80 to day 100. That's why people choose Plans C! H or F, these plans will pay 100%

Advantage plans are all over the place with no cut in stone rules.

@Carmie thanks so much for sharing this info. I worked as a rep in the health insurance industry and even sold the Medicare supplemental contract but that was about 25 years ago and clearly things have changed since then because I wasn't even aware of these Medicare Advantage contracts. -- I put my parents on the Blue Cross coinsurance which has been great but, of course, I checked through the benefits (and exclusions) first.

This is a bit of oversimplification on my part but these Medicare Advantage contracts sound a bit like the "healthy person" insurance contracts that Cong. Ryan would have liked to have set up... which can be very expensive just as soon as you are no longer healthy.

-- bebe

bebe777 · ‎12-10-2012

@Carmie wrote:
@Kachina624 wrote:
@conlt wrote:
I have said it many times on these boards and people always argue with me but the Medicare Advantage Plans do not pay just like Medicare. I have worked in health care specifically with the elderly as a RN executive in home care. My business is a Medicare business. I think the advantage plans are fine for a healthy individual who wants to save money on prescriptions however, I have seen many times when they don't want to take care of someone who needs more intensive care. When Medicare rolls around for me I am taking straight Medicare, a supplement to cover the other 20% and then a part D drug plan. My 91 year old mother is on this and she never pays a dime for anything other than her insurance. Please be careful with the Medicare Advantage plans, you never know when a critical illness is going to happen and you need good coverage.
@conlt I don't know what you're talking about because my plan has no maximum lifetime limit. Mine also has a part D drug plan. It covers everything I would ever need. These plans are not all the same.
I know what she is talking about. I worked in Health a Insurance for over 25 years, and I agree with Halo117.

You might be surprised what your Advantage plan does not cover at 100%. You won't know until you need that benefit.

One of my family members is in the hospital right now. She has an Advantage plan that covers just about everything. She pays $90 a month for it.

I just checked into her benefits today. She has a $200 deductible for the first through the 7th day of an inpatient admission. She has been there four days already and will probably owe $1400 at least for seven days when she is discharged.

She used to have Traditional Medicare and Plan F which paid 100% of all her inpatient admissions. She dropped that insurance on Jan. 1. I have no idea where she will get the money to pay this bill. She is living on $1200 a month from SS.

@Carmie yikes! This is an important example of why it's so very important to thoroughly have your plan checked out in advance by someone who understands the ins and outs of the various plans.

-- bebe

bebe777 · ‎12-10-2012

@Carmie wrote:
@KarenQVC wrote:
Another thing, you may not qualify for all the days your plan may pay for. You have to require skilled nursing or intensive rehab. If you don't make progress in rehab, you are discharged. Bummer.
Once you reach your maximum improved potential, you are no longer covered. Maintenance rehab is not covered in a SNF.

You are 100% correct. That is true of all policies. You need long term care insurance to cover those types of services.

@Carmie, excellent advice.

When I'm talking to the health care decision makers, who are frequently in the social work division, I like to use the terms "medically necessary" (skilled care) versus "custodial care" becasue that alerts them that I know what my rights to Medicare benefits actually are. -- Once I've used these terms, they provide a much more detailed description of what care the patient is eligible for and they don't try to give the patient the bums rush.

I explain that before the operation that the patient had a certain level of movement, speech, etc. and that the patient needs Skilled Nursing Facility (SNF) care or outpatient physical therapy in order to get back to their pre-hospital level of movement/speech/cognitive ability.

I also mention that I realize that the patient may not me able to get fully back to their pre-hospital level of movement/speech/cognitive ability. -- And that once the patient's new level of movement/speech has plateaued that the SNF care or physical therapy will be ended.

I make it clear that we are not looking for custodual care but for skilled care (either SNF or physical therapy).

Decision makers on medically necessary care can include (but are not limited to): physical therapy providers (physical, occupational & speech), social work departments, and the SURGEON. -- Your surgeon may well tell you that other departments make the decision but I have clear, conclusive evidence from two cases that this is NOT true. And as my dad's general practitioner said, of course the surgeon has major input because they performed the operation and have the most medical knowledge. lol, the surgeons just don't like being pressured by both the insurance companies... and the patients.

___

Recommendation for any older adult:

Have a video of you taken now (while you are well) which documents the extent of your movement and speech.

After my dad had his stroke, the neurosurgeon was clear that he would be going to a SNF. My dad rebounded so well for his age (late 80s) that within a day the neurosurgeon was backing off of his recommendation and telling me that the PT department made the final decision.

I could see that my dad was onlyat 70% of his pre-hospital movement and cognitive ability. Luckily we had video of interviews he had recently done with authors which could show that his movement and cognitive ability had diminished. -- I sat down with each of the physical, occupational & speech PTs in the hospital and showed each of them the video. They each immediately acknowledged that my dad needed SNF care. lol, I made sure that everyone who came in contact with my dad (including the social work department, neurosurgeons, interns, residents & nurses all saw that video). The result was that my dad got 21 days in a SNF and a good deal of in-home speech therapy care (which helps with cognitive improvement as well as speaking).

___

Medically mecessary / skilled care -- care by a medical professional that results in an improvement of the patient's movement, speech or cognitive ability.

Custodial Care -- help with doing day-to-day tasks. A few examples would include: help bathing, getting dressed, making meals, etc.

___

-- bebe

bebe777 · ‎12-10-2012

@Carmie wrote:
@Kachina624 wrote:
I have a Medicare Advantage Plan and was in a rehab facility 2 weeks after knee replacement surgery in 2011. I didn't pay a penny.

Your friend should have received information from her carrier regarding her coverage, which may be different from mine. Not all Advantage Plans are the same. Why doesn't she call her company and discuss it with a representative? They would be able to tell her what the limit of her coverage is and how she would appeal a decision with which she disagrees.
Two weeks of rehab is covered by all Traditional and Advantage plans if medically necessary if you spend at least three days as in inpatient,

The OP is talking about months of rehab. You would need Traditional Medicare and a supplemental Plan C, H or F to get 100 days paid in full. ( there are other plans that cover SNF too up to 100 days) , but these are the most popular,

You cannot appeal your benefits. You can only appeal a denied claim or a claim that you feel did not process correctly according to your purchased benefits. If the claim paid correctly, there is nothing anyone can do. You get what you pay for.

@Carmie thank you for sharing this info.

-- bebe

bebe777 · ‎12-10-2012

@tucsongal wrote:
@conlt wrote:
I have said it many times on these boards and people always argue with me but the Medicare Advantage Plans do not pay just like Medicare. I have worked in health care specifically with the elderly as a RN executive in home care. My business is a Medicare business. I think the advantage plans are fine for a healthy individual who wants to save money on prescriptions however, I have seen many times when they don't want to take care of someone who needs more intensive care. When Medicare rolls around for me I am taking straight Medicare, a supplement to cover the other 20% and then a part D drug plan. My 91 year old mother is on this and she never pays a dime for anything other than her insurance. Please be careful with the Medicare Advantage plans, you never know when a critical illness is going to happen and you need good coverage.
-----------------------------
I would heart this post 10 times if I could

@tucsongal and @conlt agreed.

bebe777 · ‎12-10-2012

@Carmie wrote:
@Tinkrbl44 wrote:
@fthunt wrote:
Don't know much - but from what I've heard about M Advantage, I wouldn't be surprised about anything. I got tricked into signing up for it and when my doctor's wife found out about it - - she had a fit. I finally got out of it and back to what I had. Good Luck to your friend.
@fthunt

How could you get tricked into signing up for insurance?
People are told only about the good things an insurance plan covers, they are not told about the things that are not covered or things that have a large deductible or copayment. The consumer is lead to believe that the plan is right for them.

The agent doesn't lie to you, they just don't give you the complete story. It happens all of the time.

@Carmie well said... unfortunately.

Unless you are a professional in this field, it's much like reading a legal agreement if you're not a lawyer... or signing a morgage agreement if you're not a banker. -- Bad things can happen if you don't get a professional to look it over and make sure that thr health insurance policy you choose it the most cost effective for you... especially for when you get really sick and, eventually, we all get really sick.

I don't find it helpful to blame the victim (here, the consumer) for not knowing enough to ask the right questions.

Frequently, the "helpful" folks who are trying to sell you a bill of goods are looking out for their best interests. Just because someone is nice, it doesn't mean that you should be trusting your future with them.

If something isn't your area of expertise, then it's always a good idea to get advise from a professional in that industry (or even a few) who isn't benefiting from this transaction.

-- bebe

NickNack · ‎03-10-2010

@151949 wrote:
@Nicknack wrote:
@BalletBabe wrote:
@Carmie wrote:
@BalletBabe wrote:
@Carmie wrote:
@Kachina624 wrote:
@conlt wrote:
I have said it many times on these boards and people always argue with me but the Medicare Advantage Plans do not pay just like Medicare. I have worked in health care specifically with the elderly as a RN executive in home care. My business is a Medicare business. I think the advantage plans are fine for a healthy individual who wants to save money on prescriptions however, I have seen many times when they don't want to take care of someone who needs more intensive care. When Medicare rolls around for me I am taking straight Medicare, a supplement to cover the other 20% and then a part D drug plan. My 91 year old mother is on this and she never pays a dime for anything other than her insurance. Please be careful with the Medicare Advantage plans, you never know when a critical illness is going to happen and you need good coverage.
@conlt I don't know what you're talking about because my plan has no maximum lifetime limit. Mine also has a part D drug plan. It covers everything I would ever need. These plans are not all the same.
I know what she is talking about. I worked in Health a Insurance for over 25 years, and I agree with Halo117.

You might be surprised what your Advantage plan does not cover at 100%. You won't know until you need that benefit.

One of my family members is in the hospital right now. She has an Advantage plan that covers just about everything. She pays $90 a month for it.

I just checked into her benefits today. She has a $200 deductible for the first through the 7th day of an inpatient admission. She has been there four days already and will probably owe $1400 at least for seven days when she is discharged.

She used to have Traditional Medicare and Plan F which paid 100% of all her inpatient admissions. She dropped that insurance on Jan. 1. I have no idea where she will get the money to pay this bill. She is living on $1200 a month from SS.
You can set up a payment plan with the hospital. They have to take what she can give. Do not give them a charge card or a debit card. They try to get it out of you while you are there. DON'T GIVE IT TO THEM.
I know what you are saying is true. The hospital won't bill her until after the claim is processed, so no CC on file.

I just don't have a clue where the extra money for this bill will come from. Her monthly bills for her RX drugs are very high. Hundreds a month because she takes so many. 17 pills in the am and 12 in the pm. She also has a mortgage and pays her utilitiy bills. My brother pays her RE taxes and I help her with her grocery bills and other expenses. Her home is in need of repair. My sons can fix things for her, but things need replaced and updated, not fixed.

There is no money left at the end of the month. Her clothing is getting worn out. Her health is not good and mentally, she isn't always "with it". Sometimes she will spend money she can't afford to or give it to the small children in the family as a gift for a birthday or holiday and her bills suffer.

She used to work in finance, so this is unlike her.

I have been trying to get the family together for a meeting, but they keep resisting.
I would suggest she sell her house and move to a senior apartment that has an income based rent. Something small. She lived with me for 9 months after a serious hip injury and back surgery, but begged to go home. So home she went home last April.

I am her POA, but don't want to make or force her do anything. I want her to except change and move on. She keeps saying, "but I want to live here in my home." Well, she can't afford to.

Lately she has been sick, hence the hospitalization. Her kitchen was so dirty and gross when I went to check on her, that I almost fell over from the stink. She was too sick to clean or do dishes.

She has always been clean crazy and used to re do everything I did because it was never clean enough for her. I just spent a whole day cleaning her home, scrubbing and deep cleaning because it was so bad.

She was sick, but didn't tell anyone how bad she was. She called me for an unrelated issue and I knew something was wrong right away. I took her to the ER still in her nightgown, slippers and robe and she was admitted.

I don't think she should live alone anymore, but I don't know what to do for her. I am going to call the office for the aging on Monday. I hope they can help or offer suggestions.

Sorry for the long rant. I just needed to vent..
She definitly needs to get off the Advantage plan. That plan is for people that are healthy and don't need meds that are expensive. You might want to have her apply for Medicaid, especially if she cannot afford a supplemental. There are also pland to help patients with low income to get help with meds. Make some phone calls! Good Luck! It is a shame that they do this to the older generation.
She may be able to get on a Medicaid plan now, but she couldn't go to Plan F. You can't switch from an Advantage plan once you're already on it. At least that's the way I read it.

That would be incorrect information. You can't switch from an advantage plan to regular medicare while you are being treated for something -- for instance if you are on an advantage plan and you get diagnosed with cancer - you can't just switch to a plan F now so they pay all your bills. You would have to stay on the advantage plan until you are through the treatments for your cancer, but then you could switch if you want to.If you aren't being treated for any major illness you could switch during the sign up period in the fall if you want to.

Thank you @151949. I read this completely wrong then. I'm glad to know this.

The Bluebird Carries The Sky On His Back"
-Henry David Thoreau

KarenQVC · ‎05-13-2010

@Carmie Here is what I would do TODAY. I would ask the hospital doctor to order a psychiatric eval. and a neuropsych. eval. It is your impression the patient has declined and you are worried about sending her home with her declined cognitive abilities. You will have this for your own info. and for the court if you need to seek guardianship. Also, while you are getting a plan together, ask the doctor to send the patient to a SNF based on weakness, whatever needs.

Ultimately, my GUESS is that the patient will need group care now, not low income apt. Look into group foster homes and assisted livings based on $ factors.

Best of luck. You have done your best.

KarenQVC · ‎05-13-2010

I wasn't explicit about this---it is so much easier to transfer the patient directly from one placement to another. If you let her go home, there will be all the trauma of driving to THE HOME. Even if it costs extra, avoid that.