My mother in law almost aged 90, fell and was in the hospital for 4 days after falling and breaking both her hip and shoulder. She is in a short term rehab placement for now only about four days in. So, she has used 8 days of Medicare 100% coverage period so far (first 20 days covered 100%) The SW staff however, suddenly is encouraging us to sign a contract to disenroll her from her Medicare Aetna PPO Advantage Plan from her former job, so it's a eduction retirement plan. The SW mentioned we will have to "appeal" every few days and that to avoid "this" they can "switch" her over to regular, traditional Medicare Pt A and B with a Medigap plan. Could it be that the facility wants to "assure" they are paid immediately? Are the "appeals" usually accepted being she isn't weight bearing for the next 6 weeks? Her Advantage plan offers up to 120 days of SNF, it's a really good plan. Anyone have experience with this at a Short Term Rehab SNF facility? I found out if we disenroll her, she can never go back to her current Medicare Advantage plan. Thank you.
With Trraditional Medicare, you have a premium every month, mine is $178. We have a supplimental that DHs employer pays for him and for me is very low. Comes out of his pension so we never see it. I agree, at her age I would not change. Hopefully, this is a short stay.
Medicare only pays 50% from 21 to 100 days. The other 50 needs to be picked up by the patient or a supplimental.
They are just looking to make their lives easier.
Just do a search for "SHIP counselor in my area" and several will come up.
These people are trained.
They are not paid by any insurance company
They are not beholden to any company
The answer focuses on making sure the proper details are in MILs notes to insure her stay.
Make all your calls to verify your position and hopefully others will weigh in on any errors in this AI explanation.
IN Addition:
The fact that she has already been there a few days does not change the core strategy, but it drastically shrinks the DIL's timeline to prepare.
Because the clock is already ticking, the DIL needs to move fast on three specific fronts:
1. The Day 14 "Danger Zone" is Looming
Medicare Advantage plans usually issue their first denial or cutoff notice between Days 12 and 14 of a stay. If she has already been there a few days, that means the insurance company is reviewing her charts right now. The DIL needs to speak to the caseworker tomorrow morning using the script provided earlier to ensure they are documenting "skilled maintenance" care before the insurance company pulls the plug.
2. Lock Down the exact Day 21 Date
Because she has already used up several days of her 20-day 100% coverage, the DIL must ask the billing office for the exact calendar date that Day 21 hits.
Count the day she was admitted as Day 1.
If Day 21 hits before the 6-week non-weight-bearing order is up, the family needs to have that $214 daily co-pay ready to go to secure her bed.
3. Ask for the "Pre-Auth" Status
The DIL should ask the caseworker: "Has the insurance company authorized her stay through Day 20, or are they only approving it 3 to 5 days at a time?" Knowing this tells the DIL exactly how closely the insurance company is watching and when to expect that first battle paper.
1.Day 21
Since her plan only covers the first 20 days. For the remaining 22 days of her non-weight-bearing period, she will owe the daily co-pay.
In 2026, this co-pay is $214 per day.
The Math: 22 days × $214 = $4,708 total out-of-pocket cost to finish the 6 weeks.
2. The Med Advan Trap
Because she cannot bear weight, she cannot do standard, intensive physical therapy. M. Advantage plans notoriously use this as an excuse to cut off coverage about Day 14, arguing that she "is not making measurable rehabilitative progress."
3. Traditional Medicare Rules
Traditional Medicare explicitly allows coverage for patients who are non-weight-bearing if they require "skilled nursing care" (such as safe transfers, skin breakdown prevention, and surgical site monitoring). Traditional Medicare will cover the full 42 days, as long as she pays that $214 daily co-pay after Day 20.
Action Plan for the DIL
The DIL must still NOT drop the retirement plan, because losing that lifelong coverage is too dangerous. Instead, use this specific approach:
Demand the "Jimmo" Standard: If the Advan plan tries to cut her off early because she isn't walking yet, the DIL must appeal and cite the Jimmo v. Sebelius legal precedent. This federal rule states that Medicare must pay for skilled care to maintain a patient's condition or prevent deterioration, even if they cannot improve or do active rehab yet.
Prepare for the Co-Pays: prepare to pay roughly $4,700 to cover Days 21 through 42.
Transition to Rehab on Day 43: Once the doctor clears her to bear weight at week 6, intensive physical therapy can finally begin. At that exact point, the rehab facility can submit a new authorization request to the Advantage plan to cover her active rehabilitation.
The DIL should request an immediate meeting with the Facility Caseworker/Discharge Planner and the Director of Physical Therapy.
She should use the scripts below to ensure the medical team protects the MIL from an early insurance cutoff.
Script 1: Talking to the Caseworker (Protecting the Stay)
What the DIL should say:
"Because my mother-in-law has a 6-week non-weight-bearing order for her leg and shoulder, we know her Advantage plan will likely try to issue a quick denial around Day 14, claiming she isn't making rehab progress.
We are absolutely keeping her retirement plan, so we need the facility to document this as a 'Skilled Maintenance' stay under the Jimmo v. Sebelius standard. She requires 24/7 skilled nursing for safe transfers, skin breakdown prevention, and pain management while her bones heal.
Please make sure the daily chart notes clearly reflect these clinical nursing needs so we can successfully appeal the moment the insurance company issues a cutoff notice."
Script 2: Talking to the Billing Office (The Co-pay Strategy)
What the DIL should say:
"We know her plan only covers the first 20 days 100%. We understand that starting on Day 21, there is a daily co-pay of roughly $214.
We want to confirm that the facility will continue to keep her in this bed through the full 6 weeks of her non-weight-bearing order, provided we pay that daily co-pay out of pocket once Day 21 hits.
Can you verify her exact daily rate starting on Day 21 so we can arrange payment?"
Script 3: What to Say When the Cutoff Notice Arrives
Private plans must give a 2-day written warning before stopping payment. The moment the DIL is handed that paper, she should call the appeal number on the sheet and tell the reviewer:
"I am filing an Expedited Appeal to fight this discharge.The patient is 90 years old with a broken leg and a broken shoulder. She is under strict medical orders to remain non-weight-bearing for 6 weeks. She cannot safely transfer, feed herself, or use the restroom without maximum skilled assistance. Discharging her right now is an unsafe discharge and violates the Medicare coverage guidelines for skilled maintenance care."
Several years ago my MIL had a Humana Advantage plan. Whenever I took her to the doctor, they'd literally just look at her member card and sign, then get on the phone to find out if they'd cover what MIL was there for.
That being said: Do not sign disenrollment papers simply because the SNF recommends it. Instead:
- Call the Aetna Medicare Advantage member services number on her card.
- Ask to speak with a case manager assigned to her SNF stay.
- Ask exactly what criteria they will use to continue coverage.
- Contact the retiree benefits office from her former employer to learn what would happen if she voluntarily left the retiree MA plan.
If Aetna eventually issues a termination of SNF coverage, appeal it before making any permanent insurance changes.
Unless there is another compelling reason, changing Medicare coverage in the middle of a rehabilitation stay is usually a major decision with long-term consequences, and it should be made only after fully understanding what benefits might be lost.
If it wasn't an employer-sponsored plan I'd be telling you to drop it and get a better supplement, like BCBS. But I don't know enough about how it works with her employer to tell you such a definitive answer. You need to further research it.
"...they'd literally just look at her member card and SIGH..."