Not sure how to handle this - my LO has been in the nursing home for about 90 of his allowed 100 days of Medicare. Last week he got the "notice of non coverage" saying he had to be out in 2 days or Medicare would stop paying. Of course we appealed; at the end of the 2nd day (Friday after 5PM) we received the denial and immediately filed 2nd appeal Saturday morning. The NH never gave 30 days' discharge notice; never had a discharge meeting; never had the interdisciplinary meeting with us saying he had met his goals and was ready to go - we have had ZERO communication with them and in fact they have told us they refuse to write down anything. We met with them today and they claim they are NOT discharging him, which is why no discharge planning was done! Medicare just won't pay for him any more! However if we want him out WE can tell them we want him discharged! At this point we DO want him out -- however 2nd appeal is pending and it seems if you ask to be discharged while an appeal is pending you are automatically liable for the $895 daily charge. However you are ALSO liable if you lose the appeal (which is likely) so if we wait until it plays out we are possibly on the hook for even more money. This seems like a trap - they didn't do their job of preparing us for a safe discharge and are now dumping the responsibility on us knowing we will have to pay. Has anyone dealt with this before? What is the best way out?
Recommendation:
- Continue with the second appeal if you believe skilled care is still medically necessary.
- Ask the facility in writing for a detailed Notice of Medicare Non-Coverage, the effective coverage end date, and a written explanation of your financial responsibility while the appeal is pending.
- Also ask in writing for a care conference/discharge planning meeting—even if they insist they are "not discharging" him—so there is a documented discussion about the safest next placement and what services he needs.
- If they refuse to communicate in writing, document every conversation yourself (date, time, who was present, and what was said)*. Send follow-up emails summarizing the conversation so there's a paper trail.
If you believe the facility is failing to meet its discharge planning obligations or is not communicating appropriately, you can also contact the New York Long-Term Care Ombudsman or the New York State Department of Health for guidance.
One question: Is your LO expected to return home, go to assisted living, or remain in long-term nursing home care (e.g., Medicaid pending)? The best strategy can differ depending on what the planned next step is.
One thing that stands out is the statement that the facility "refuses to write down anything." If that's literally true, I'd be concerned. Nursing homes are required to maintain medical records and provide various written notices. If they are refusing to provide written explanations of decisions affecting coverage, discharge planning, or financial responsibility, that is something I'd raise with the ombudsman and, if necessary, the state survey agency. It doesn't necessarily mean they've violated the law, but it's unusual enough that I'd want it documented.
* Personally I would record any conversation with them as anything verbal can just be denied, whether or not you take notes. If you do take notes make sure you get the first and last name of the person you talk to. I would also not hide the fact that I'll be talking to an ombudsman about their refusal to follow the protocol and put things in writing.
There is no 30days notice. Medicare only pays for Rehab not Longterm Care. Once the 100 days is up, you will be expected to pay privately for your LOs care. If you want this stay to be permanent, you will pay out of pocket or will need to apply for Medicaid. If you are a married couple, you will need to see an elder lawyer to split your assets so LO can get Medicaid.
He should not have come home that day and I barely managed to get him in the door. It was an absolute nightmare. He was home for three more months until he fell and we placed him in a SNF from the hospital. We informed the hospital he was an unsafe discharge.
In hindsight what should have happened that day is I should have appealed but as I said there was no social worker who could have guided me through this. All I knew was my parents could not afford to pay this bill and he had to come home.
And by the way this was a facility in NYC.
Currently, you can refuse to take him home if it is unsafe for you to provide care. He cannot be dumped out on the street. If you are the spouse with deep financials, then this is the real world. Medicare only covers up to 100 days. It does not cover custodial care, This was not trap. You did not understand Medicare and it seems that he is not ready for a safe discharge and may never be ready if you expect him to come out 100% better. Major illness with a 100 day stay in SNF has bad outcomes.
You need to see an elder lawyer ASAP to get educated about separation of finances and Medicare max. You will still be given homework to bring in all current statements of your assets. At over $800 per day, I would be sprinting.