REWahoo
Give me a museum and I'll fill it. (Picasso) Give
That defies logic. Were I you, I'd consult with an Elder Law attorney in Mass to see what can be done to help your brother.
Around here there are no 'Medicaid NHs'; you can be paying full freight and the person next to you could be on Medicaid. Same care.
In fact, (I'm running into this with my recently disabled brother) Medicaid recipients are given a wider set of benefits than a self-paying person is legally allowed to pay for. In my state, I've learned that my brother was a chump to have worked every day, saved his money and build assets; HE should've partied his money away and he'd be better off.
Too long a story to go into here.
Agree - different states have different rules. One can't extrapolate to the whole country from local experience.Some home are private pay only and do not accept Medicaid patients, the idea is if you might spend all of your own money you want to be sure that you don't have to abruptly switch someone to a different nursing home. We ran into this with my MIL who has Alz. The private pay was much nicer and cost more, which doesn't matter when the money will run out anyway, but we didn't want to set her back by changing to a different home. She always went backwards with big changes like that. She spend 6 years in nursing homes.
Got that covered with a family attorney on an annual retainer.That defies logic. Were I you, I'd consult with an Elder Law attorney in Mass to see what can be done to help your brother.
If insurance denies additional coverage it would be only because it deems them unnecessary (correctly or not) and that might lead to a regulation that does not allow a provider to recommend continued, cash coverage.
Other states may vary but... bear with me, all of this is new to us.
Ok.
Short version:
My brother has had a stroke and insurance has been paying for his NH therapy (PT, OT and SLP) but plans to drop paying for his therapy at the end of this week. His progress is good but not as fast as they'd like so after 3 months of PT, they're done paying.
He's done so well and made so much progress with his therapy I want to pay for it out of pocket to continue his sessions.
In some twisted logic, the great state of Massachusetts says it's illegal for one to self-pay for therapy after insurance drops you. So starting next week the NH can only provide very limited therapy for him within the limits of the law. No matter what amount of money I want to pay, they cannot do it.
Going through all of this with the NH I was told that had he come in the door on Medicaid, his therapy would have been virtually unlimited and that some people there have been doing therapy for almost a year.
A therapist took me aside and told me that the Medicaid side of things "gives you tons of stuff that you can't get paying...try to get him on it asap"
YMMV but that's the game in Mass.
Honestly how did this rule ever come to pass, who on earth benefits from it..it's mindblowing and greatly disturbing.
That exact same thing with stopping physical therapy happened to my best friend's mother, a private paying patient, in a different state. All of the kids are lawyers and couldn't get it overturned.
So can you get around it by driving him to Pt somewhere else instead of it being provided in the nursing home?
This would be a situation where what is actually happening is easily confused.
A: Is the NH saying that PT is being stopped because insurance will no longer pay? B: Or is it being stopped because insurance will no longer pay and they will not allow the PT to be purchased private pay? C: Or that the doctor involved will not prescribe further therapy session?
My guess is that the situation is the former. the insurance company is ceasing payments because inadequate progress is being shown. And there may be the issue of getting the doctor to recommend further therapy and prescribe it.
It's really easy to get Medicaid, Medicare, private insurance and private pay intertwined and confused. At least for me.
It was B following C. In my friend's mother's case it was that the family wanted the PT to continue as they saw continuing improvement, same as with Marko's brother. Money was not an issue and they were more than willing (and most supremely able) to pay outside the Medicare and her private insurance that had paid for the first three months, but the PTs said treatment had to be authorized by the NH, and I'm sure the PT's certification or licenses or the liability insurance could be jeopardized without the NH's authorization. The mom was in her mid-90s and had had a bad fall that the PT was treating; I can see that improvement might be limited at that age but the family was upset they couldn't pay for "elective" PT. In this case tho there was nothing said about a Medicaid patient would have been authorized for further treatment (as Marko had been told). I brought this up only because it was very similar to Marko's post but in a different state, so possibly driven by Medicare vs state Medicaid policies.
That defies logic. <snip>
Dear Mr. REWahoo,
Many things the government does defy logic.
Reading between the lines in marko's post, it seems there is a disagreement on how well his brother is progressing with therapy. His private insurance and the doc that prescribed the therapies are saying that progress is inadequate to meet their standards to continue.
Marko's issue is getting a prescription for further therapy sessions from the doctor and then finding a provider that will administer it.