How to coordinate medicare and long term care insurance
July 26, 2016 7:42 AM   Subscribe

My great aunt is in a nursing home for rehab due to a broken hip. She has dementia and the nursing home says they have to discharge her because she's not making progress. I have no idea what to do next.

My aunt fell at home and broke her hip about a month ago, she had a successful surgical repair and was discharged to a nursing home for rehab. She has dementia and doesn't understand/refuses (we're not exactly sure which) the PT and so she hasn't gotten to a point where she can stand or walk. The nursing home says that since she's not making progress they will discharge her this week or she can stay if we self pay. She has medicare and long term care insurance but it seems like neither of these will cover her staying in a nursing home. There's nobody that can care for her at home and I can't figure out this maze of insurance coverages, rehab, memory care, medicare spend downs etc. What is my next step? Who should I talk to about this?

This is in Florida
posted by anonymous to Health & Fitness (13 answers total) 2 users marked this as a favorite
Does the nursing home employ or can they refer you to a social worker experienced in these issues? I know that would be the next step at most hospitals, where they are often on staff.
posted by charmedimsure at 7:45 AM on July 26, 2016

Whatever you do, don't allow a family member to accept custody of her from the nursing home until you have it figured out. They will try to strong-arm you into taking her home, but don't agree until you have the next steps clearly sorted.
posted by quince at 7:59 AM on July 26, 2016 [18 favorites]

Don't let them pressure you into taking her home, ever. They need to work with you to discharge her to an appropriate environment.

MedicAID covers long term care once you've spent down. I would think that long term care insurance should also cover it--you might call the insurance company yourself or look at the policy if you have access to it.

Does your aunt have a health care proxy, and power of attorney in place? These are essential and if not, you should move on these ASAP. Have them done by a true Elder Care Attorney ( or you may later find the documents are worthless. This person may also be able to help you navigate the financial and responsibility issues around this move.
posted by Riverine at 8:15 AM on July 26, 2016 [1 favorite]

Get your family to talk to a lawyer who specializes in Medicare/Medicaid/long term care. I just watched my best friend navigate this with the assistance of a lawyer, and even with that help, it was a labyrinth that took a long time to get right.
posted by xingcat at 8:16 AM on July 26, 2016 [1 favorite]

My mother was in a similar situation. She was dropped from a rehab program in the nursing home due to non-compliance, and never regained the ability to walk. However, due to dementia, she was placed in a memory care program in another wing, where she remained until the end. Rehab for an injury such as a broken hip is not "long-term care", but memory care is, since Alzheimer's and other dementias never get better. You should check the particulars of the long-term care policy. As for Medicare, no, they do not cover either in-home nursing or nursing home care for more than a few weeks if I recall correctly. Your great-aunt would subsequently have to pay out of pocket for nursing home care (I truly hope someone in your family has obtained power of attorney to pay her bills out of her accounts) until nearly penniless, at which point she would apply for Medicaid, which would provide total coverage until her death. The nursing home will also take her Social Security check. This is the sad but true state of affairs for the elderly in the U.S.

As others have recommended, please see an elder care attorney ASAP.
posted by RRgal at 8:44 AM on July 26, 2016 [4 favorites]

You might also see if there are any PT's in the area who understand and can work with dementia patients. It's heartbreaking when this happens, and can be very frustrating. I went through some of this with my own mother.
Best wishes to you.
posted by dbmcd at 8:56 AM on July 26, 2016

I am a social worker in a skilled nursing facility (not in Florida). When someone has dementia, it's not uncommon for them to be discharged from a Medicare stay due to non-participation. Do you know what her long term care policy does cover? It surprises me that it wouldn't cover care in a nursing facility or memory care unit, although there are millions of different policies and they all work differently. Some require that the policy holder pay for a certain number of days before the policy will pay, and there are usually stipulated amounts they will pay toward care that may or may not be enough to reasonably cover your aunts expenses.

I agree that it would be worthwhile to contact an elder care attorney, and would also suggest that you check Florida's Department of Elder Affairs website to see if they have case workers who could help you navigate the system. The website has lots of info about different programs, and the federal Medicare/Medicaid website also has helpful info.
posted by odayoday at 8:57 AM on July 26, 2016 [1 favorite]

It looks like Florida has Aging and Disability Service Centers set up across the state to assist with coordinating care and finding programs that someone might qualify for. Sometimes the answers you get in this type of situation aren't great, but hopefully they could at least point you in a good direction to start.
posted by odayoday at 9:08 AM on July 26, 2016

Don't agree to anything until you have consulted a social worker or case manager and/or an elder law attorney. Hospitals and rehabs try to strong-arm families into taking elderly, demented patients home all the time! This is because they find that it works to get rid of the patient, especially if the hospital/rehab is dealing with an equally elderly, often confused and grieving spouse, or a grieving and harried family. So stand firm. They can't force you to take your aunt home or dump her in the street.

If you, or someone, has power of attorney, it's going to be a lot easier. A social worker can work with the POA to find memory care for your aunt. If nobody has POA - you need a lawyer ASAP. My grandma never designated anyone as POA, so my mom had to get it after Grandma became demented, and it was a huge hassle, but it got done.

Make your first stop your local Department of Aging (in my state they are organized by county). Here is a link to the Florida Department of Elder Affairs which should be able to guide you.
posted by Rosie M. Banks at 9:24 AM on July 26, 2016

Do not agree to take her home. Make them place her in a safe environment. They want you to believe that you have to take responsibility for her safety. That is not true. The burden is on them.

It's really hard and stressful. Good luck to you and your Aunt.
posted by cairnoflore at 9:40 AM on July 26, 2016 [1 favorite]

Do not take her home. She is unable to care for herself and you have no one set up to care for her.

Nthing consulting with the care facility's social worker, who will likely discuss long-term care prospects in alignment with her insurance coverage. Advocate for a placement that is easy for family & friends to visit and encourage her progress. What likely has happened is she is at the end of rehab and they need a new plan. You can say that she does not have a place she can be safely discharged to. This happened with my dad, who transferred to a wheelchair exactly once and was otherwise bedridden, and lived in a walk-up by himself. The reality was we didn't have the capacity for his home care. He had lovely carers for his long-term and hospice care.
posted by childofTethys at 10:39 AM on July 26, 2016

My mother was discharged from rehab care when she failed to make medical progress, which is the standard for Medicare. It will not pay for dementia care long term. Her long term care now covers assisted living based on dementia We had to private pay for a couple months while the application for long term care was on file and pending. I would look at that policy and file application as soon as you can. When long term care runs out, I hope that Medicaid will kick in, tho we will have to go through another process for that.
posted by Cocodrillo at 5:30 PM on July 26, 2016

Definitely talk to an elder-law attorney. Most, if not all, will do free initial consultations. I tried to research this stuff for my in-laws when my father-in-law became a quadriplegic, but it quickly became apparent that the laws and system are so complicated that they needed to talk with an actual lawyer. Unfortunately I couldn't convince them to actually do so (fear that it woud cost too much), so they're struggling along without any assistance for the level of care he needs.

I did convince MIL to come with me to one educational presentation given by an elder-law attorney. It taught me that there are options. But you really do need help navigating them. The nursing home social worker may help, but is likely way overworked, and won't be able to help with all the details.
posted by snowmentality at 5:55 AM on July 27, 2016

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