My mother broke her arm 2 weeks ago and was taken to the emergency room but never admitted to the hospital. She's unable to stay in her apartment due to other health issues complicating her mobility. Her doctor wrote an order to have her admitted to a local nursing home. However, we've been told that Medicare won't pay for this.
In general, the nh business office and social worker can help you with these issues.
My question was, and still is, IF my mother were to fall or have some other problem while at the nursing home AND IF that issue caused my mother to have to be admitted to a hospital for care AND IF this hospital stay was 3 days or longer AND IF she was then returned to the nursing home because she was still unable to be safe alone in her home, THEN WOULD Medicare pay for her care?????
You may find that it could be hard to get mom admitted to the hospital. The NH should be able to provide a lot of care, after all that is so much of what they do & why one is in a NH. The medical director & the DON (director of nursing and the power center of the NH) are going to have to go along with this. Her old MD may not have a lot of input on the decision making as the medical director is the contact person for her care once in a NH for the most part, this was my experience.
Also keep in mind that lots of procedures & care at hospitals / medical centers are now out-patient to begin with. And more & more hospitals are doing the "observation" route - so they technically are not IN the hospital - even after what would have been considered in hospital surgery.
Fall and breaking a hip, now that's a hospitalization if their coming from their home. But my mom fell @ the NH and broke her hip, and instead went onto hospice as she was at the point in lack of cognitive ability in her dementia that she could not do rehab. Physcially she would have been OK most likely for surgery & anesthesia but not good mentally to do what would be needed for rehab. So hip break not guaranteed hospital. So a "Whatever Happened to Baby Jane" moment might backfire (just trying to keep your sense of humor going in this as all this is nothing but humorless at times……)
Many people don't realize they haven't been admitted to the hospital, even after spending days or weeks in a hospital bed. The story of Lee's husband Larry is one of many, many examples of hospital patients who were not covered by Medicare when they were released to a nursing home:
https://www.agingcare.com/articles/hospital-observation-status-can-be-financially-devastating-175991.htm
A SELF HELP Guide from the Center for Medicare Advocacy suggests you find out right away if you are only in the hospital for “observation.” If you are, try to get that status changed to “INPATIENT.”
medicareadvocacy/self-help-packet-for-medicare-observation-status/
If your mother is an inpatient, discharged from the hospital after 3 midnights for skilled nursing home care, Medicare will cover room and board until she no longer needs skilled services in the nursing home.
Co pays and other details of Medicare Covered Care in a Skilled Nursing Facility at:
https://www.agingcare.com/articles/Medicare-coverage-of-skilled-nursing-facility-153265.htm
Since your mom was just seen in the ER, she doesn't qualify for MediCARE paid in-facility rehab. But MedicAID will pay for NH.
To get mom admitted to NH coming from her home or IL can be done but will require work on your & her part. I moved my mom from IL to NH and bypassed the AL stage or being in hospital prior. Medicaid will pay for NH care if mom qualifies. Your mom will need to show 2 things: to be financially "impoverished at-need" & medically "at need for skilled nursing care" (the doctors note helps with this but she will need items in her chart showing need for continuing long term skilled nursing care - if mom could get better once her arm heals she won't qualify).
Personally I'd look at her finances first and what your state has set for income & assets to see where she stands for financially qualifying for Medicaid. If she is looking like she has a spend down to do, then look at several NH to see which to place her into as 100% private pay now and then "Medicaid Pending" for later; and speak with the medical director of the NH about what she need to have in her file to qualify medically for Medicaid later on and if she appears to justify skilled care needed.
If she's on the borderline for truly needing skilled nursing, a NH will take her in as a private pay resident since she has her doctors note. Then the medical director of the NH and nursing staff can add to that for her stay to show the continued need for skilled nursing care if she has health issues that can be documented. Some things are simple to change that work - like changing their Exelon from a pill to a patch as the patch requires "skill" to apply; or having medications needing to be compounded which requires skilled services. But whatever the case, she will clearly need to show "need", just being old or forgetful or not being 100% on her ADL's is probably just not enough to need skilled nursing care.
Most states have it so that their non-exempt assets cannot be more than 2K and their monthly income about $ 2,050. Each state administers it's Medicaid program uniquely so you need to see exactly what the requirements are. based on posts on this site most elders coming from their home seem to have some spend-down to do before Medicaid will pay. The Medicaid application will require all sorts of documentation on assets - from life insurance policies to years of bank statements. None of it is simple but for NH either it's private pay, long term care insurance or Medicaid needed. Good luck & keep a sense of humor going.