After a hospital visit, such as after a fall or other health issue, your elder may need to go to rehabilitation at a Skilled Nursing Facility (SNF). At the SNF, the patient's health insurance (either Medicare or an HMO/PPO) will pay for some or all of their stay. Medicare pays for 100% of the rehab for days 1-20 and there is a co-pay of $200/day (2023) for days 21-100. When the patient has an HMO or PPO, the health care benefits are similar, but not the same. This article will discuss certain important aspccts of health insurance for when your loved one is in the SNF and the family is trying to fiture out next steps.
When does Rehabilitation End?
Medicare/Health insurance will only pay for rehabilitation under certain rules. Mostly, insurance will pay for rehabilition when you are getting stronger, but once you get strong enough, your rehab will "plateau," meaning further rehab will not get you stronger. Medicare covers skilled nursing care and skilled therapy services under skilled nursing facility, home health, and outpatient therapy benefits when a beneficiary needs skilled care to maintain function or to prevent or slow decline, as long as:
- The beneficiary requires skilled care for the services to be provided safely and effectively
- An individualized assessment of the patient’s condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist are needed for a safe and effective maintenance program
While this can be complicated, you need to know the insurance is there to pay to get your loved one stronger or prevent decline, but it is not there to pay for long-term care after insurance stops paying for rehab. If you want to learn more about Medicare insurance standards, please visit this webpage.
Should I keep my HMO/PPO (Medicare replacement) if I am in the SNF?
This is a tough and important question! Under some scenarios, you may not want to keep your elder on the HMO or PPO and instead move them to Medicare. This is known as "flipping" the patient from health insurance perspective.
Why "Flip" someone to Medicare?
When someone is in the SNF, we want our loved one to rehab, to get as strong as they possibly can, and have insurance pay for it. Rehabilitation is our friend as it may help us go home or to assisted living, or it may give us time to decide where the elder should go next. The problem is that Medicare is better at paying for rehabilitation compared to an HMO/PPO. The general rule is:
HMOs/PPOs are good until you get sick
This means that you may want Medicare at this point to pay for rehab, which will likely give your loved one more time to get stronger.
Should I Flip my elder to Medicare?
Maybe. The key is that Medicare provides better rehabilitation benefits than an HMO, so if we want more time to rehab, Medicare is our friend. The problem is that if you only have Medicare and you do not have a Medigap plan, you are forced to pay the co-pays yourself. If your elder is going to need Medicaid, we probably want to flip them to Medicare as Medicaid will pick up any co-pays. If your elder is going home or assisted living without Medicaid, you probably do not want to flip them.
How do we time "Flipping" to Medicare?
Health insurance works on a month-to-month basis. This means that if you want to flip your elder to Medicare, you have to do it by the end of the month! Here is an example of how you want to look at things:
Mom, age 90, falls at home and goes to the hospital. Mom has a 4 day hospital stay. She has a Medicare Part C HMO. Mom moves to the SNF to get stronger. The HMO will approve 2 weeks of rehab at this point. After 2 weeks, Mom is not doing well and not as able to participate in rehab.
IF we think that Mom will not be able to go home, we may want to "Flip" Mom to Medicare to help pay for her rehab longer. THE KEY, though, is that we must flip her onto Medicare by the end of the month! If Mom went to the SNF on the 20th of the month, the HMO will pay for about 14 days, leaving the possibility that the HMO will stop paying for rehab after the start of the following month. This means that you may want to Flip to Medicare as soon as Mom gets to the SNF, especially if you think your Mom will need Medicaid.
Who will Flip my elder?
The social worker or business office at the SNF will be able to help you here. If not, a good elder law attorney can help you make this decision.
When do I apply for Medicaid?
If you think your elder will stay in a nursing home, or may go out to assisted living, you may want to get Medicaid. Now would be a good time to consult an elder law attorney, like us, to assist you, which may involve asset protection planning.
We want Medicaid for the Assisted Living Facility, right?
Maybe. While every situation is different, Medicaid is helpful for assisted living, but it only provides about a $1,500/m subsidy for the facility. We have more on Medicaid and assisted living on this webpage. So now may be the right time to get Medicaid. We have more on Florida long-term care Medicaid here.
What are other questions I should ask if my elder is in the SNF?
If your loved one just went to the SNF, you may have a lot of questions. This page on our website may be able to help you.
Conclusion
All of this is complicated. The key for you is that if your loved one is in the SNF and you are thinking about Medicaid/asset protection planning, now is the time to call our law firm!
