MORE REASONS TO REVIEW YOUR COVERAGE

My neighbor sold a truck today to pay off his deceased wife’s medical bills. He said he just got a bill from the ambulance company and his portion was $800.00. I asked him if he had his Explanation of Benefits from the insurance company and if it agreed with the bill. He replied he didn’t know where it was, but he was sure he owed this. He went over the bill with me over the phone. From the best I could tell, he read off the billed charges, and the amounts paid by his insurance company. The exact balance was what he thought he owed. He didn’t indicate to me if there were any adjustments on the bill. Hmmm. I of course asked him what his deductible and out-of-pocket was. His reply was, “Don’t really know – couldn’t really tell ya”. Wow, so he’s just going to pay his bill! He didn’t really want any “help” because the ambulance gave them good service. REALLY!!!!  I told him if he wants me to go over his bills and make sure they’re correct I would. I could do this even after he paid them, just in case he’s due a refund. I also mentioned that lots of places will set up monthly payment plans with you, and some will even discount the bill if you agree to pay a lump sum right away. Again, he didn’t really care. This seems pretty scary to me, especially since he wife was in the hospital for 3 ½ weeks and had two more trips via the ambulance that he hasn’t received bills for yet. Enough said……

Skilled Nursing Facilities: Medicare Qualifications

My little aunt passed away on Halloween. Everyone pretty much expected this, she had been in failing health for several years and her body just could not hold on anymore. She would have been 89 years old on Nov 14. 

She had been living at home for the last few years with the assistance of her daughter and son. A few days before she passed she became unresponsive and more lethargic than usual. She was taken to the hospital and was admitted. It was determined that she had suffered a stroke and had a bladder infection. She was in the hospital for two days, then discharged back home under the guidance of home health and hospice. Even though she was in very poor condition, the hospital would not keep her. They sent her live out her final days at home.

I do not live in the same town as her, but asked my mother why she wasn’t transferred to a Skilled Nursing Facility (SNF). Apparently, one has to meet certain criteria to be admitted to an SNF. She did not qualify because she had to be an inpatient in the hospital for three consecutive (and not just for observation), days before Medicare will approve SNF care.

 

For those of you who are not familiar with SNF’s, they are where patients go for medically needed long-term care or rehabilitation and they have the required staff (Registered Nurses, Licensed Practical and Vocational Nurses, Physical and Occupational Therapists, Speech-language pathologists and Audiologists.), to manage, observe and evaluate such care. They are able to give medications, IV’s, injections and physical and occupational therapy. Sometimes theses are referred to as “nursing homes”.

Medicare will cover certain skilled services that are needed daily on a short-term basis (up to 100 days) and will only cover it if you carry Medicare Part A (hospital insurance). In addition, there are several other requirements that you must meet in order to qualify for SNF care. Some (but not all), of these are ~

   ■     You must have days left in your benefit period.

■     You must have a qualifying hospital stay, (three consecutive days or more, starting with the day the hospital admits you as an inpatient, but not including the day you are discharged). If you were “under observation” in the hospital for any of this time, it will NOT count toward your 3-day qualifying hospital stay.

■     You must enter the SNF within a short period of time, (generally 30 days), of leaving the hospital

■     You require skilled care on a daily basis and can only be provided in an SNF as an inpatient.  

Obviously, there are many other guidelines to be admitted to an SNF, but these are just a few. Each patient’s case is unique and will have to meet the criteria for his individual circumstance.

How long can you stay in an SNF? Medicare uses a benefit period-of-time to keep track of the number of days you use in an SNF and how many are still available. This starts on the day you start using the SNF coverage in a benefit period. You can get up to 100 days in a period. Once you use those 100 days, your current benefit period must end before you can renew your SNF benefits. There is no limit to the number of benefit periods you can have, however once a benefit period ends, you must meet Medicare requirements before you can get up to another 100  days of SNF benefits. If at some point you no longer qualify for Medicare coverage, you (or if someone is acting on your behalf), must be given a written “Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage”. This notice informs you that the SNF believes you no longer qualify for SNF services paid my Medicare. It has to state:

    ■     When your Medicare coverage will end and when you must start to pay.

    ■     The reason why your stay is no longer covered.

 ■     Your right to request that the SNF submit a claim to Medicare so you can receive an  official payment decision from Medicare.

 ■     That if you request to have a claim submitted to Medicare, you are not required to pay for your current SNF stay until you are informed of Medicare’s decision, (but you will still be required to pay any coinsurances and for services not covered by Medicare).

 ■     Where you should sign to show you got the Notice.

If you do not agree with the decision, you can file an appeal. You will be responsible for SNF charges if Medicare denies the appeal and determines you do not meet the requirements for additional SNF care. One such option is a fast (expedited), review or an immediate appeal. During this process, an independent reviewer called a Quality Improvement Organization will look at your case and decide if your health care needs to be continued. The SNF should give you information on how to contact them within the allotted timeframe. Be prepared to supply information (evidence), why you think you need the additional stay.

Lastly, you can also choose to pay for SNF costs yourself when your Medicare coverage ends. Long-term care is quite costly and many patients use other resources to help cover these costs. Always check with your state or county to see if you qualify for additional benefits (such as Medi-Cal in the state of California). You would be surprised to find out that there may be other options to help you pay with these costs.

RIP Aunt Alvera. Give Grandma and Grandad a big hug and kiss for me and tell them that I miss them and think of them often.