IBM Medicare OneExchange Medicare and custodial services coverage

For a number of years, I have been a volunteer with the Medicare Rights Center. From time to time I handle a call from the son or daughter of an elderly person with early dementia who is being release from the hospital after a fall or medical problem.  The caller always feels the patient is not ready to be release back home because of both their mental and physical condition. They want to know how to stop the hospital from releasing the patient. These calls are really difficult because there are no quick and easy answers to offer. The answer starts with a rather flat statement.  Medicare does not cover custodial care aka long term care.  If the patient is physically able to walk a few steps, has no other treatable medical problems, and the doctor does not prescribe any physical therapy then the hospital is going to release them.
     
This is the kind of situation that requires advanced understanding of Medicare coverage otherwise the caregiver will use the wrong words when appealing to the doctor, the hospital, and Medicare.  If they talk about the dementia, they will be told Medicare does not cover custodial care and appeals will be denied.
   
What does Medicare cover?  Medicare covers remedial care.  That is, Medicare covers rehabilitation. That can be provided in a Skilled Nursing Facility (SNF) or as an outpatient.  The purpose of remedial care is to stop the patient from getting physically worse.  It used to be that the patient had to improve. Those Medicare rules were changed about a year ago.  Knowing about Medicare remedial coverage can provide the right words to goad the doctor, hospital and Medicare into transferring the patient to a SNF and might give the caregiver some time to determine next steps as well as improve the patient's stamina.

The right words need to revolve around physical condition.  That means, in a case where the patient is elderly, the words need to be about how the patient's strength has waned from being in a hospital bed and how they need physical therapy to regain their strength before they return home or they will risk injury.  Those words are really important to use if the caregiver must do an emergency appeal to Medicare to stop the hospital from releasing the patient. The case to be made is the doctor and hospital are doing an inadequate job assessing the patient's strength and ability to walk. Risk of injury is also important to say.  DO NOT use ANY words about cognitive problems aka dementia. There is no rehabilitation for dementia.  Dementia falls into the category of long term care.

This is only a temporary fix to buy time.  The caregiver needs to do advanced planning regarding custodial care. Many people make arrangements for the elderly person to reside with them.  If that is not an option, then it may be time for a nursing home. The only private insurance that covers nursing home costs (which are substantial) is long term care insurance. The older a person, the more expensive the insurance premiums. Even for younger people, the premiums are substantial.  Medicaid is the only government insurance that provides custodial care but eligibility is limited to low income people with few assets. The rules for Medicaid vary from state to state.  In New York, if a person is low income (less than $1000/month)  and has few assets they might be eligible for Medicaid.  New York also has a program called Medicaid spend down which allows expenses for medical treatment to be subtracted from a person's income to determine Medicaid eligibility.  If the person qualifies for Medicaid, they are eligible to go to a Medicaid nursing home.  However, government budget reductions have caused the services in Medicaid nursing home facilities to diminished in recent years. It was never stellar.

AARP and other organizations are lobbying congress to include custodial care coverage in Medicare or provide people with the ability to buy into Medicaid because by 2020 about a third of our population will be over 65.  Given the current congressional opposition to the Affordable Care Act, it's a long shot. Petition your legislators if you believe more government remedies should come into play to help the elderly population deal with long term care costs.

There are no easy options for custodial care.  But knowing the right words to say if you encounter the described situation might provide you some short term relief while you consider your options.