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Bill Demand During Medicare

Question: After being treated at a local hospital for five days due to a stroke, my husband was discharged to a nursing facility for rehabilitation. His doctor told me he would need at least four weeks of rehabilitation. It was my understanding that Medicare would pay for the first 20 days and, if necessary, part of the next 80 days; however, the nursing home told me after ten days that Medicare would not pay and my husband would either become a private pay patient or be discharged. We are not wealthy people, and I certainly can’t afford to pay $120 per day for his room. Is there anything I can do?

Answer: The nursing home has notified you that it has made an initial determination that your husband’s care will not be paid by Medicare. If you dispute the nursing home’s reason for assuming that Medicare will not pay, contact the facility administrator to find out why. If you believe the facility is wrong, you have the right to request that the facility submit a “demand bill” to Medicare. While waiting for Medicare’s response, the facility can not force you to pay the amount set forth in the demand bill; however, be advised that if Medicare determines that your husband’s condition does not meet Medicare guidelines, he will owe what is due.

We urge you to contact a geriatric care manager to assess your husband’s condition to determine if continues to need skilled care and, if now, whether he meets the level of intermediate care. If so, you should contact an elder law attorney to determine if your husband will qualify for Medicaid. If so, and you file a Medicaid application, the nursing facility cannot discharge him.

Question: My husband has been in a nursing facility for nearly two months, all of which has been paid for by Medicare and our Medicare Supplement policy. At the last care plan meeting, I was told that even though he would not be able to come home, Medicare would stop paying for his care at the end of the month, and that I would have to make other arrangements. We own our home and have only $60,000 in savings. His total monthly income from Social Security and his pension is $1,600 and my Social Security is only $400 per month. How can I afford to pay for his care privately?

Answer: You can’t. That’s why you should consider Medicaid as a pay source. Federal Medicaid law provides special economic protections for spouses of nursing home residents (called the “community spouse”), and each state has established different levels of asset and income protection.

  • Asset Protection: By federal law applicable in all 50 states, an institutionalized spouse seeking Medicaid benefits can retain $2,000 of “countable assets” and certain “non-countable” assets. As a community spouse, you can keep the amount of “countable” assets established by your state along with certain “non-countable” assets, such as your home. Assuming your husband qualifies medically, he should be for Medicaid once your countable assets have been reduced to level established in your state.

  • Income Protection: By federal law, if your spouse becomes eligible for Medicaid, all of his income, less certain deductions, will be paid to the facility. These deductions include a monthly personal needs allowance, a deduction for non-covered medical costs (including medical insurance premiums), and, since he is married, a monthly allowance to you as the “community spouse.” Your income will not be used to support him in the nursing home. Your share of your husband’s income each month -- called the “minimum monthly needs allowance” -- varies in amount from state to state and will be determined by a formula based on your expenses.

Taking the NextStep: Contact an elder law attorney in your area to learn about your options before you spend all of your money and leave yourself destitute. At a minimum, check with state agency which handles qualification in your state to find out these amounts so you can begin the planning process. Visit the NAELA website to find an attorney HERE

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