Long Term Health Care

[REWahoo]

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.

 

[Bestwifeever]

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.

 

[MichaelB]

Is your brother on private insurance or Medicare? Private insurance cannot "drop him". It can set a limit on some types of coverage (such as PT) and require prior authorization to continue. once the limit has been reached. 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.

If that's the case, it would be no different under Medicaid, which also has limits on PT and requires specific authorization to continue once the limit has been reached. Medicaid is a state managed program, so it's implementation is different across the country, but it is not a program that covers everything, and in fact has many limitations.

 

[ivinsfan]

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.

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.

 

[travelover]

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.

Agree - different states have different rules. One can't extrapolate to the whole country from local experience.

 

[marko]

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.

Got that covered with a family attorney on an annual retainer.

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.

That's exactly where we are. He's doing well but just not fast enough for the insurance to keep paying his PT.

What the NH told us is that had he entered the NH on Medicaid his benefits for PT would be much more generous and he'd be all set but once insurance drops his PT it's against the law to private pay for it.

Only something like 25% of NH in Mass are self pay; all others are Medicaid. Medicaid (aka MassHealth) LTC in Mass is not considered inferior but the standard. We got a few cringes when we told people there that he was going to self pay.

Other states may vary but... bear with me, all of this is new to us.

 

[REWahoo]

Other states may vary but... bear with me, all of this is new to us.

Looking forward to hearing how this works out - and hoping for the best for your brother.

 

[Brat]

Weird!!! Can you hire your own PT??

 

[ivinsfan]

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.

 

[marko]

Honestly how did this rule ever come to pass, who on earth benefits from it..it's mindblowing and greatly disturbing.

I think the idea is this: Someone determines that you're not progressing (fast enough). Insurance drops your PT. Suddenly you show up with money and an unscrupulous NH says "great! right this way! we'll take your money and give PT"

See? My state is just looking out for me and I really appreciate that.

 

[Teacher Terry]

So can you get around it by driving him to Pt somewhere else instead of it being provided in the nursing home?

 

[youbet]

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.

This would be a situation where what is actually happening is easily confused.

Is the NH saying that PT is being stopped because insurance will no longer pay? Or is it being stopped because insurance will no longer pay and they will not allow the PT to be purchased private pay? 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.

 

[youbet]

So can you get around it by driving him to Pt somewhere else instead of it being provided in the nursing home?

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.

 

[Bestwifeever]

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.

 

[youbet]

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 makes sense. But it does seem like the family could seek out a second opinion from another doctor and possibly get a prescription for further therapy. The second opinion doc could be informed that his position would not be used to challenge the first doc or the insurance company (putting him in a situation he might have to defend), but rather just to open the door to additional therapy sessions paid for privately.

Even if docs contacted for the second opinion suggested that further therapy was extremely unlikely to yield positive results and refused to prescribe, at least the family could be more content knowing they had done all they could do.

I know NH's are leery of providing, and charging for, therapy deemed unlikely to be helpful due to some of them being historically abusive (money grubbing) in the past. Since the client is private pay, if there was a prescription for therapy and the current NH would not allow it to be filled there, the family could shop for another NH (an advantage to being private pay - choice) that would accept the prescription.

If you aren't allowed to private pay for therapy in a NH, I wonder what would happen to a wealthy person, too young for Medicare, who was private paying for his medical care? That is, private paying to be in the NH and private paying for his docs and medical services due to no insurance. Apparently his docs would not be able to get him needed therapy because he would be paying for it himself?

 

[Chuckanut]

That defies logic. <snip>

Dear Mr. REWahoo,

Many things the government does defy logic. For example, a single mom on welfare (housing aid, food stamps, child care, Medicaid, etc.) gets a job paying about $500 a week after taxes. She loses so many benefits she ends up, in effect, paying a marginal tax rate in the area of 70% to 90% depending on her income, the various programs and state rules. Even our wealthiest billionaires don't pay a marginal rate that high.

Sorry to hijack the thread.

Respectfully yours,

Chuckanut

 

[REWahoo]

Dear Mr. REWahoo,

Many things the government does defy logic.

I had no idea.

 

[marko]

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.

No.

I agree that my brother's progress is not as fast as insurance would like. I also reluctantly submit to their ending to pay for therapy.

My point was the lunacy that it's illegal to pay for additional therapy on your own and that according to the NH, had he originally arrived already on Medicaid, he'd still be receiving therapy for an extended period because Medicaid has a different set of standards than the insurance company does.

That was my whole point.

Sadly folks, I've spent too much time on this as it is and I must end my participation in this thread. It's just too draining and I need to focus on my brother's issues right now.

I hope this has helped the conversation a bit however.