When my elderly mother suffered her first round of pneumonia  due to aspiration, she ended up in the hospital where the doctors  installed a peg tube.  I was advised she had to go to a nursing  home, when released.  Since she was Medicare qualified she  would go into Skilled Nursing. The case worker at the hospital and two staff people at the nursing  home I selected all explained it as:  Medicare will pay everything for  “skilled nursing” for the first 20 days.  Since my mother had a peg  tube installed, she qualified for 100 days (certain conditions warranted  longer time).  I asked repeatedly “Medicare pays for everything up to  100 days because she has a peg tube?” and was told yes.

They were wrong.  Medicare pays everything for 20 days.  After that,  under certain conditions, they pay for everything EXCEPT $133.50 per  day.  That amount goes up every year.  Operating under the assumption  Medicare paid 100%, I encouraged the therapist to continue working with  her to improve her swallowing technique.  It didn’t really help, but we tried.  After 31 days, she was released from “skilled” into long term care. I was surprised by the invoice I received from the nursing home for those  extra 11 days.  That’s when I learned, everyone *meant* to say “Medicare  pays for everything up to 100 days EXCEPT for $133.50 per day”.  We paid  the money and I’m glad she had the extra therapy, but it blew our budget  out of the water.  If your relative doesn’t have supplemental insurance (or  the nursing home is out of network for some supplemental policies), you
will have to pay the extra amount.

I should’ve called Medicare and asked.  I trusted the case worker and the  nursing home staff.  I had the government Medicare booklet, but due to  stress and worry, it was difficult to wade thru the double-speak of government  publications.  There’s a toll free number (800-633-4227).  If you’re dealing with  medical expenses and Medicare, call them.  You don’t want any surprises.

Susan D

 

16 Responses to Susan Dw – mother, peg tube, medicare, expenses

  1. Karen says:

    Hi Susan, I am so sorry for your loss of your mom as well and was so sad to read about it tonight.

    My mother has Alzheimer’s and went into a nursing home this past spring from a hospital stay for a rehab stay covered by her insurance. She has the supplemental Medicare insurance plan through BCBS. Hers paid 100% for the first 10 days and after that we had a $100 co-pay per day at the $200/day nursing home she was at. We knew about the up to 100 days max per year stay, but also that had to be approved through Medicare. So basically the nursing home has to give a good reason to Medicare to approve her stay there. However, what we did discover through our own investigating with the insurance company on the phone once she got out that she has a yearly dedectible for everything and once that is met, she does not owe a dime more the rest of the year and that includes regular doctor co-pays, everything except pharmacy drugs. So in other words, you know how you start getting the onslaught of doctor/hospital/lab bills, etc. We needed to be careful we didn’t pay certain bills that we didn’t owe

    • Karen says:

      (oops, sorry, wasn’t finished, I must have hit the wrong button) anyways…BECAUSE SHE HAD ALL READY MET HER YEARLY DEDUCTIBLE. So for you and everyone else out there, that is something to be aware of. I don’t know if it applies to you Susan with the straight Medicare it sounds like you were going by, it may, I don’t know, but everyone needs to know what their yearly deductible for maximum out of pocket co-pays are.

      One thing that you mentioned that I’m not aware how it works is you said Medicare put her from the nursing home into Long term care. May I ask you what that was for her exactly? I still have tons to learn about all these things still and am just wading through the waters myself trying to gather as much information as possible.

      Again, so sorry for your loss and the confusion from the incorrect or insufficient information provided to you by these facilities. During these times of crisis we often assume we can rely on these hospitals and nursing homes to know or have all these details worked out, or at the very least they should provide us with a written statement of costs at the time the patients go in. Perhaps there should be some regulation on that.

      Karen

      • Susan D. says:

        Sounds like your mother has excellent supplemental insurance. My mom had a supplemental policy as well BUT they didn’t pay anything for “out of network” care. This is another situation where I dropped the ball. I assumed the nursing home was acceptable because they were Medicare approved. Not so. They weren’t “on the list” so we had to pay. “Long Term Care” is a basic classification. Don’t know if it’s the same across the country, but here it means general care for people unable to care for themselves. I had hoped she would enter their Alzheimer’s Unit, but it was full. Although she could walk, she was very unstable. She couldn’t dress herself or bathe herself, so the staff took care of everything. She didn’t stay in this particular nursing home (another lesson learned) but the last place also had her in Long Term Care.

        Susan D.

        • Karen says:

          Hi Susan, my heart goes out to you with the loss of your mom and I think I can understand that feeling you described of that jolt you feel sometimes when you think of her not being with you any longer. Although some of us like myself haven’t lost our mothers yet, we realize how vulnerable they are in their current conditions and as difficult as it is to see them not well I find myself feeling that panic inside sometimes with that realization that she could be gone tomorrow unexpectedly and it’s very disconcerting. I’m glad you also know that she is happy and out of pain too now. To quote one of Dan’s songs regarding death it’s there to “keep us honest and constantly remind us we are free.”
          And believe me I have dropped the ball many times myself in other matters regarding her issues too. We get worn down, tired and at the end of the day there are only so many hours available to take care of everyone and still keep your own sanity and stay in survival mode, so please know you did the best you can and your mom loves you very much for it and she is smiling and staying close with you from heaven.

          Take good care Susan and keep in touch with us and let us know how you’re doing,

          Karen

  2. Melisa says:

    Hi Susan, you were an amazing daughter and your Mom was in more than excellent hands with you. I am very sorry for your loss of your Mom. It will take time and things will level out at some point. Your Mom was a lucky woman to have you in her life and you did all the right things. I will be checking in to Medicare for my boyfriend who is disabled and is only 48 so you have given me the confidence to ask all the pertinent questions and to be sure I understand everything they are saying. Thank you again. Melisa

  3. Susan says:

    Susan, thanks for passing the info on, but sorry you had to go thru that conflict. This is all very helpful for me. My mother lives with us, has only Medicare, no supplement and I know the time is coming when we will be dealing with similar situations. So I am absorbing all this information as much as I can. I hope and pray things are going better. Blessings-Susan

    • Susan D. says:

      Actually, although things are better now, my mom passed away June 29th. This was one of those “lessons” I learned and wanted to share for those of you dealing with similar issues. During my second visit to the hospital, I did try to find the case worker to explain the actual Medicare rules. She was no longer at that hospital. My gut feeling is she was unaware. The staff at the nursing home knew (I suspect) and failed to mention it so they could continue to charge the “skilled nursing” rate for extra days. Sounds cynical of me, but that particular place turned out to be a disappointment in many ways. So, when dealing with Medicare, don’t be afraid to call and ask them to verify what others claim.
      Susan D.

      • char says:

        Hi Susan, My heartfelt sympathy on the loss of your mom,I am so very sorry.Just to recap, the information you provided for us is very helpful. To be a situation, like you were, and to know the right questions to ask, is so important. Thank you for allowing us to learn from your “mistakes”, and I mean that in the nicest way possible. Thank you again, Susan, and I hope each day brings you closer to healing, my thoughts and prayers are with you at this time.
        ~Char

      • Ann says:

        Hello Susan,

        You have my condolences as well. I didn’t realize when you initially posted that your mother was deceased. I hope that you are coping well w/her death. Never feel that you are cynical about the red tape of health care, especially in these difficult economic times. If you were unhappy w/the nursing home for other reasons, there’s a definite possibility that information re: financial coverage may have been withheld from you. Thanks for giving all of us the heads up. I will say my prayers for you and your family members. If you ever need/want to share anything else w/us in the future, be assured that many caring people are here to support you!!

        Love,
        Ann

        • Susan D. says:

          Thanks for the condolences and warm thoughts. I’m doing okay. There are times I stop and realize “my mom is gone” and that gives my heart a jolt. Mostly, I’m so relieved for her. She was in bad shape and suffering and there wasn’t anything I could do to change that. Although I miss her, I don’t wish she could still be here. I know she’s in a better place and having so much fun. So, I’m okay. Thanks again for the positive wishes.

          Susan D.

        • Ann says:

          Hi Susan,

          I wanted to add that, while it’s OK to be a bit cynical, I hope you don’t get too jaded. As others have mentioned, it’s hard to know how knowledgable the nursing home staff was or wasn’t about financial coverage matters. Just chalk it up to being a learning experience :-) I’m so glad that you are generally relieved that your mom is no longer suffering. She is still w/you in spirit…

          Love & Prayers,
          Ann

      • angelina says:

        Susan, my heartfelt condolences on your Mom’s passing. Thank you for posting the medicare hassle you experiences. I experienced something very similar this Winter when I lost my husband’s insurance (divorce) and had to jump through all the hoops with his employer and Social Security to get Medicare Part B reinstated. I was so distraught that I couldn’t even talk to people on the phone (big bipolar episode). It is good that you can breathe a bit easier know that her suffering is over. I pray her soul in resting comfortably in God’s hands or she is having a great time in heaven. I know this post is over a year old, yet I wanted to thank you for your advice on double checking what is and what is not covered by insurance. It’s quite a shocker to get those big health care bills unexpectedly.

  4. Ann says:

    Susan, Thanks for sharing your unfortunate Medicare mix-up and the toll-free phone #. I’m so sorry that you received some inaccurate info. and then had to pay for it (literally). Your story reminds me what I’ve learned from my parents when it comes to all things financial-ask as many questions as you need and make addtl. call/contacts when necessary. Whatever it takes for you to feel secure and certain that you are armed w/all of the facts you need. Also, it’s never too soon to be prepared for the unexpected, because you never know when life might throw you a curve ball. Thanks again, Susan, and hang in there:-) I hope you got back in touch w/the case worker to let her/him know you were given incorrect information!!

    ~Ann

    • Ann says:

      Hi Susan, After I thought about what I wrote earlier, I wanted to make sure I didn’t sound too harsh about approaching the case worker. You WERE mislead, but maybe the case worker (sadly) didn’t have the up-to-date facts, either.

      I would just make sure you contact this person and repeat what you believe you were previously told about Medicare coverage. If the case worker still agrees, I’d definitely inform her/him what actually happened.

      I’m just stressed, because we’re leaving on vacation tomorrow, and I HATE packing, because I’m not the most efficient at it. Also, for so many years, I’ve been packing for myself and one or both of my daughters-often for week long + trips. UGHH!!!

      Thanks for understanding :-)
      ~Ann

  5. char says:

    Susan, thank you so much for taking the time to inform us of this situation. The information you have provided is very much needed. Thank you again.
    Hope you are well.
    ~Char

  6. Anonymous says:

    Hi Susan, what a huge bit of information, thank you for sharing. It is the hardest time in the world to weed through health insurance, money etc. when we are managing our emotions and all that goes with being with someone we love. It’s unfortunate, but trust no one and you have given us the reminder to call direct and how to do it-thank you again! We have found that there is always someone that knows something, one has to search to find that person though……This site is a great resource and I go to it everyday. Susan, my thoughts are with you and keep on writing to tell us how you are doing. Melisa

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