Happy Holidays 2023, Now Is The Time, Wade's Words

Your mom is working her way through the stages of the “revolving door” pattern. Now it is time for discharge from the hospital. In the event the patient needs inpatient rehabilitative services before going home, the question becomes whether the cost is out-of-pocket or covered by Medicaid A.

The criteria for Medicaid A coverage is that (1) the patient was admitted to the hospital for skilled treatment for at least three consecutive days, (2) the doctor writes an order for inpatient skilled rehab services, and (3) the condition requiring rehab is the same one initially treated in the hospital. If one or more of these elements is missing, then the cost of rehab services becomes the patient’s responsibility.

The key to Medicaid A coverage is that the patient requires treatment from licensed professionals (PT and OT) to maintain, improve, or slow the decline of the patient’s condition. The duration of coverage is up to 100 days: days 1-20 are covered 100%, then the patient shares the cost of treatment with Medicare on a per diem basis (around $176/day).

The adult child caregiver should expect the medical staff to start the discharge process by the 20th day of treatment. The typical reason given is that Medicaid A coverage will terminate because the patient is “no longer making progress or their recovery has plateaued.” This is not the legal standard for termination of coverage. Medicaid A coverage is to continue up to 100 days, as long as the patient requires skilled care to maintain, improve, or slow the decline of their condition. Please note that if the patient does not try or fails to cooperate with skilled treatment, then coverage will terminate by day 20 for sure.

The patient’s advocate should determine from the medical staff that the patient will continue to require skilled care beyond the 20th day as soon as practical. The facility must give written notice that Medicare coverage is stopping and advise the patient of the right to appeal the decision. The problem is that such notice is often sudden and feels like it came out of nowhere for the unknowing caregiver. Appeal the decision to terminate coverage to gain a little more time. Once the appeal is denied, the patient will become responsible for the bill going forward. If the patient is unable to pay the per diem rate, then the facility will seek to discharge the patient.

May 11, 2022