One of the things that sets me apart from other local Independent Insurance Brokers is that I am also a Licensed Nursing Home Administrator or ‘HFA’ in the state of Indiana. I was responsible for the entirety of the Nursing Home operations in multiple facilities over my 15 years in the industry. This included overseeing the insurance contracts and ensuring residents on short term rehab stays got the therapy and nursing care needed while also billing all the different Medicare benefit carriers. This gives me a unique and justified perspective on managing a Rehab stay for Medicare Beneficiaries who have Advantage Plans. I promise you; it is doable! I hope that the following points help debunk any myths or negative things you may have heard about Advantage Plans and Nursing Home Rehab!
Nursing Homes Need Support
I want first to point out that the amazing people that work in the Nursing Home industry are some of the most selfless and hardest-working people I have ever met. They do the work that most people could not do. They are all short-staffed and under-resourced. It doesn’t mean they don’t care or try their best to do all the right things! I feel for my colleagues every day. There will always be a place in my heart for those vulnerable and fragile residents and the staff that is expected to do so much with so little. Now with that said……
Please Stay in Your Lane
To my Nursing Home Admin friends: STOP giving short term rehab stay patients and their families insurance advice. You are NOT an insurance expert. I have had to manage some frustrating scenarios where Nursing Home Clinical Navigators, RN managers, etc. have told patients and/or families that they should not be on an Advantage Plan or simply it is better (i.e. they would get better care) if they had Original Medicare with a Supplement Plan. This is, unfortunately, a misrepresentation and can lead to people making knee jerk decisions which can have very negative effects when they return to the community with less coverage for all their other needs. Nursing Home Staff, including Admin, are great at their jobs. They know very well how to strengthen with therapy, manage critical medications, fight infections, and treat patients with dignity and respect. They are not experts at managing someone’s entire comprehensive insurance coverage needs. If you are getting therapy in a Nursing Home for a short-term rehab stay, this is only a part of your healthcare journey. You return home and still have other parts of your healthcare journey that need to be managed.
How to Manage Your Stay with Advantage
If you need short term rehab after hospitalization and you have an Advantage Plan, the first thing you’ll be directed to do is choose a facility that has a contract with your Advantage Plan. Since Managed Care is steadily growing, this is getting easier to do. More and more facilities are contracted with major carriers. Another growing trend is Nursing Homes being run by larger companies with more contracting resources to do the job. Once you are placed, you have the first 20 days covered in full, no matter what plan you are on. The same is true with Original Medicare. However, you still must meet the criteria to stay. In other words, you must show progress or have a skilled nursing need with constant order changes or tweaking. The staff must submit clinical notes frequently to either Medicare or the Advantage Plan. The difference becomes the processing or review of those notes. Medicare is notoriously slow at everything, so it will take a full quarter or sometimes even a year before they audit those clinical and therapy notes to justify a continued stay. However, insurance companies are much faster and more efficient in this process. They have clinicians reviewing those notes in real time. They are following Medicare’s actual guidelines but just faster than Medicare is. This can lead to you being told your rehab stay coverage is ending. So what happens if you need to stay longer?
Private Pay or Home Health
Warning…this section may be a bit controversial. The facility RN Manager will tell you that you could stay longer with no expense if you were on Original Medicare. This is a misrepresentation of how it works. Here is the deal: When the insurance says you have met goals or are no longer making progress, they are not actually saying you must go home. The insurance company is simply saying they will no longer pay for room and board because it doesn’t meet Medicare’s criteria. If you need to stay longer, you will just have to pay privately for room and board and still receive the 24 hour nursing care and services. This is expensive and most people do not want to pay for it, so there is the option to return home and utilize in home services like home health care or companion care. Let’s be honest: no one desires to spend a long time in a rehab facility. Most would rather be home. The staff should refer to a Home Health Agency to ensure a smooth transition. However, there is a safe alternative option to going home. You can also begin to consider Assisted Living communities. Yes, all of this costs money, but it may be time to be honest about your loved one’s situation and ensure they are safe and in the best environment. You can also seek out state and federal aid to cover costs.
The Bottom Line is….
Advantage Plans are wonderful for so many people. They include Medicare standard benefits but with so much more. And you may have years to experience all the great benefits before navigating a Nursing Home Rehab stay. If that day comes, take a breath (you or your loved ones caring for you) and find all the options for a continued stay or at home resources. And most importantly, if a staff member at the Nursing Home tries to tell you to change coverage or that your insurance isn’t good take it with a grain of salt and then consult your insurance expert to help!
CDI can help you through this entire maze. We can meet in person or virtually. Reach out if you would like more information. Email carrie@cdi-cares.com or check out www.cdi-cares.com for a contact page and other helpful blogs.