When Medicare Won’t Pay for Mom’s Stay

“But wait… I thought Medicare would pay for Mom’s nursing home stay,” said yet another friend as I stood in her kitchen sipping coffee, watching her open her mail.

Thus started a whole conversation about what Medicare covers, doesn’t cover, and how to prepare for moments like these.

In a medical emergency the last thing you need is more to worry about. That’s why most people don’t stop to research whether or not Medicare and health insurance will pay for whatever care needs to happen in that moment.  

And yet, if you’re like so many in the Sandwich Generation, and you want to be a good advocate for your family members, you need to be aware of certain Medicare rules.

Like the rule that Medicare pays for very few nursing home stays, and only under very specific conditions.  

My friend’s mom did NOT meet those conditions.

In this case, Mom was in the hospital over several days to recover from a fall. Now, it’s not unusual after a hospital stay for someone to need physical rehabilitation. It’s amazing how debilitating it can be lying still in a hospital bed while you recover from your primary injuries.

Especially for seniors.  

For exactly this reason, Medicare covers rehabilitation stays in skilled nursing facilities, but only after a “qualifying hospital stay.”  

Aha: “qualifying.”  

In order for a hospital stay to be “qualifying,” the patient must be admitted for at least three overnights. But being IN the hospital is not necessarily an “admission.”

With the changes in Medicare’s reimbursement rates now being tied to readmission rates, hospitals are more cautious than ever about “admitting” a patient.  And in fact, sometimes they don’t formally admit a patient, but instead hold them for “observation.”

Which means mom can be in a hospital bed, undergoing tests and receiving medical care and not actually be admitted.

If you’re not admitted, you’re not accruing the necessary time you need to be considered to have had a “qualifying hospital stay.”  And that can mean the difference between Medicare paying for your rehab before you go home, or having to pay for it out of your own pocket.

Nursing home rehab stays can cost up to $500/day. That’s a costly mistake to find out after the fact.

Having a Health Care Proxy means you have someone to ask questions and advocate for you in a medical crisis. If you have elderly parents, make sure they have a Health Care Proxy so you can advocate for them.

We bookmarked the medicare.gov site on my friend’s laptop while we were standing in her kitchen. And I reminded her that her lawyer may be a great resource for ongoing questions about her mom’s healthcare.

If you’re an existing Ingle Law client, we include Health Care Proxies and Durable Powers of Attorney in our Plan Care and Priority Access Program. Just let us know your parents need them, and we’ll get on it!

If you have any questions for us, CLICK HERE.



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