Hello,
I hope someone can help me. I'm a nurse but not a social worker or case manager so need help on these things.
My mother 1.5 weeks ago fell and broke her femur (already had THA on that limb years ago) and required special surgery at a hospital in the big city (level 1 trauma) with a special surgeon. Notably my Mom has a history of falling frequently due to severe neuropathy and not being able to feel her feet.
She's now in a "boarding" section of the hospital and supposedly the social workers and medical team have tried to get her approved at a SNF for rehab (she needs intensive physical therapy) but everyone turns her down. They say that because she has a UHS Medicare Advantage plan, they won't pay for her at a SNF because she can't bear weight. They tell her and my Dad that if they had just plain Medicare that those SNFs would accept her no problem. She can't bear weight because the surgeon says she can't on that foot until a few weeks later when they'll do an X-ray to determine if she can put weight on it at that time. Meanwhile she's losing mobility and she needs to try to use her other leg (which is like jello to her) with intensive PT. PT/OT sees her on alternate days. They tell my Dad if he (he's 82) could have a family member take time off work and between him and a family member she could be taken care of at home. Or to find a SNF and pay out-of-pocket until she can weight-bear and then move to her one of the "covered" SNFs by UHC. All this smells of someone not quite doing their job.
I know our healthcare system in the US if broken and the bureaucracy is looking like an obstacle to my Mom having the chance to walk again. They only allow one visitor a day and I'm getting this info all from my Dad who is told all this information from people at the hospital. I'm going to go early tomorrow or the next day to the hospital (it is far away) and try to speak to the MD, PT and social worker to find out what's up because something doesn't add up. They seem to have given up hope on my Mom and want her to get out of the hospital. I hope they don't bring up the HINN form. I've read info on the Jimmo settlement and feel like their careplan/documentation is not accurate enough and that is why everyone is denying her. I have talked to a case manager friend of mind who is going to look into some stuff but I need your help on this forum to guide me further. I'm an expert in nursing but not in case management/medicare/social work.
Bottom line: My Mom possibly will never walk again if she doesn't have daily physical therapy and that's something we cannot provide out of home nor should we have to out-of-pocket. She needs inpatient rehab for a little while with intensive PT and then we may need home health at home but she certainly can't go home right away. I'm willing to talk to someone on the phone about this if need be so I'm armed with the correct info when I go see my Mom and talk to everyone at the hospital.
Thank you!
Others on this forum can probably provide some sort of guidance for your other coverage questions.
Medicare contracts out with these people but you are under the rules of the MA. They are HMOs and PPOs meaning you must stay in their network to get the advantages. With straight Medicare you can go to any doctor who takes Medicare. My friend had a MA and needed surgery. A Medicare doctor was in walking distance from her house but he wasn't in her MA network. It was causing problems because she couldn't coordinate her surgery. It was open enrollment season so she switched back to straight Medicare.
Your parents maybe better going back to regular Medicare and paying for a secondary insurance and prescriptions. Your Office of Aging could help u decide what is best for your parents.
Our health care system does need a lot of work, but I'm not sure that inflexible insurance companies like the one your mother has are actually "broken", but rather are cheap, just plain cheap!
I would in spare time research how to get back to straight Medicare, with a good supplemental plan We've had BCBSM for years and never had a problem with multiple hospitalizations, SNF stays and home health care.
If you don't get anywhere with the MD, PT, and/or social worker (probably also the discharge planner),go to the admin/exec suite and very professionally ask for assistance, on HOW to get PT for your mother. Stand your ground.
Some hospitals in our area have their own PT facilities, either as part or extension of the hospital services, or in a related subsidiary or support organization. I'm also thinking that a religious own rehab facility might extend their staff to help you find ways to pay for the rehab. My experience was (a) it was the only rehab we've used that had REAL psychological staff full time, and that (b) they went out of their way to accommodate us, including me, when my father was there at the end of his life.
Last resort would be to bring some adverse publicity to the insurance company. In my area, local newscasters love stories like these; it not only gets them publicity, but enhances their ability to reach out to the community for problem solving.
Can you imagine the effect on UHS of such negative publicity? And if you purchased the coverage through an insurance agent, bring him/her into the picture, with firm advice that you'll never rely on them again.
And BTW, when you speak with the hospital staff, don't raise the issue of yes/no; take the position of HOW to get your mother help. Don't let them weasel out of responsibility. It would help if you could have a relative of friend accompany you, if not for moral support, to keep an eye on the staff and observe eye contact and unspoken responses.
My sister (psych nurse) taught me that. In our first meeting with the rehab facility which wasn't performing up to par, she warned Dad and I to take seats at different angles so we could each observe the various staff participants, and see how they reacted to the issues we raised.
Regarding Jimmo, I think it will be hard for you to get services using Jimmo as reason. Jimmo imo not really applicable to the situation.
For those unfamiliar w Jimmo, it’s a 2013 settlement of a class action Jimmo V. Sebelius (Katherine Sebelius was head of DHHS 2009-2014, so head of MediCARE). Jimmo, the plaintiff, was diabetic, legally blind, amputee and on MediCARE. She had been receiving in-home Health & out-patient therapy (OPT so skilled care by PT, OT, ST). MediCARE paid in the past but stopped as Medicare started to apply “improvement standard” for determining if Medicare would pay. Jimmo did not meet “improvement”. Jimmo was the lead plaintiff but the others were MS, ALS or in LTC due to preexisting conditions. I’m familiar w Jimmo, as I had a cousin with secondary polio on in-home OPT & the agency he used sent out Jimmo notifications.
Jimmo settlement requires Medicare to look beyond “improvement” alone for claim determination; & those who can benefit from skilled services for “maintenance or to prevent or slow decline or deterioration” are entitled to Medicare benefits.
The issue, imho, will be that for your mom there is no “maintenance” for her to stay at. All her issues are recent & significant. Sounds like she needs a rehab benefit to happen before can even be at maintenance. She needs rehab done to be able to get at a baseline. Terms of the Advantage plan is the issue, not Jimmo imo. I’d try to see if their plan has any rehab places that are in network (even if further away) & get her discharged from the hospital & transferred there as a patient for post hospitalization MediCARE rehab benefit. Rehab coverage is usually 20/21 days at 100% and then coverage at a copay only if progressing. Not improvement but progressing in rehab.
Jimmo seems best used if:
1. Have preexisting condition like MS, ALS, Parkinson’s, paralysis (like my cousins w polio) as they need “maintenance” or therapy “to slow or prevent decline”
2, getting skilled services in their home.
For residents in LTC NH, they can use Jimmo to have Medicare pay for PT to do “gait training” for walking or OT to do hand movement therapy to keep ability to grab & clench. Both would fall under “maintenance to slow decline”. My mom had gait training paid by Medicare 2-3 times wk in rehab area of NH till she finally had a fall & became bedfast. It’s not Medicare rehab coverage but Medicare coverage “to prevent further deterioration or preserve current capabilities”. To me, the issue will be that your mom does not have “current capabilities”…. She needs to get rehab started to see where she is for capabilities.
If that UHC MA plan won’t budge, I’d call CMS (centers for Medicare & Medicaid) to see if your folks can switch back to Original Medicare ASAP and before she is discharged from the hospital. The discharge planner at the hospital I would think has some experience in this.
Please realize that if Dad takes Mom home from the hospital, getting her into rehab or a NH later will be difficult. It just may be that a hard decision needs to be made that mom flat just needs 24/7 oversight for care and Dad cannot do this and there isn’t enough family to do all that would be needed all the time so it’s more about finding a LTC facility. I know this is can be hard to accept. You could ask for a needs assessment to be done as that provides on paper exactly what her care needs are. & you can evaluate if at all feasible for dad, you, etc at home.
If it’s leaning to LTC NH is best, I’d find one that accepts Medicaid. Mom may need to private pay a couple of months while dad / you find an CELA level of elder law atty to sort out their finances to get mom on the path for Medicaid should they not have the assets to pay for LTC for years. It’s a lot to deal with. It will be overwhelming but you can get thru this. Speak with fellow RNs to get thier viewpoints as well. Good luck.