Question about nursing homes and insurance coverage. Any social workers?

Question

My father since Feb. has been a dialysis patient and since late March has Medicare. He has Aetna insurance. Aetna is primary now, Medicare wont be until 18 months I believe. On the 23 of July he had a fem pop bypass (on leg). And his kidney doctor, not the surgeon, requested he stay some where for rehab. In our city there was I guess only two choices a nursing home or a rehab unit of a local hospital. Well while in the hospital we found out the nursing home only covered his insurance, so he has been their 10 days. Well now I received a call today that the admissions people want to talk to us because now they found out Aetna only covers if he has three therapies. He is having two OT and PT. And actually they had to stop PT because every day he would bleed from one of the wounds. We visited the surgeon yesterday to looked at the area that was still bleeding and he said they should of never had you walking, it was too soon so he had to put staples to close the wound. And the nurse practitioner of the doctor said really she believes they wanted to rush therapy because every visit to the PT unit at the home is being charged. Any ways the lady couldn’t tell me much on the phone but said to come in, and she sort of sounded like for us to try to find a way to pay out of pocket for the days. Whose at fault, shouldn’t of they look in the coverage before or at least a day or two after he was brought in? Well I hope no one ever goes through this. A few times my dad leg would bleed and soak the dressing. We would tell the nurse if she could change it and they would do it hours later. Thanks!

Answer 1

Health insurance and Medicare do not cover nursing home stays.  They only cover "skilled nursing stays."  Both can occur in the same building, but the specifics behind them are very different.

The difference between the two is that "skilled nursing" requires a level of care that only a licensed medical professional can provide (for example, a certain number of hours of therapy per day).  

It sounds like your father isn't qualifying for a skilled nursing level of care without the therapy.  Unfortunately, neither insurance nor Medicare will pay for days in a nursing home that aren't at a skilled level of care.

(By the way, most major insurance companies base their definition of "skilled care" off Medicare's definition.  So, your father would probably have the same issue whether Aetna or Medicare was primary.)

Is there something about your father's medical condition that requires the daily attention of a licensed medical professional (registered nurse, etc) aside from the therapies?  Or is he only in this nursing facility for the specific purpose of receiving therapy?

Unless there's something else about his condition that would warrant a skilled level of care, you have 2 choices...

Pay out of pocket for the days until he's ready for the therapy, or take him home until he heals enough to tolerate therapy and return to the facility.

I presume that the doctors and nursing facility have provided all the relevant information about your father's medical condition to Aetna.  If not, make sure they are providing all the details.  Aetna can only make their determination based on the information put in front of them.

Answer 2

The insurance is restricted to those facilities that they have contracts with. That is why your father had fewer choices with where he could be placed.

If he doesn't meet the level of care required for the facility he is at, the facility is required to notify him in writing of this and there is usually a time allowed to find a lower level of care that is covered before the costs come out of his pocket-usually 2-3 days.

He may be at a skilled level of care (more because he needs medical care for his surgery and because he cannot tolerate the therapy at this time.)

Talk to the provider-they usually have contacts at facilities that will accept him at his level of care and I would suggest that you contact the insurance company as well to confirm what benefits are payable. Medicare will cover 120 days of skilled nursing if that is the level of care he requires.