Medicare Question

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LITeacher
Posts: 58
Joined: Mon Aug 07, 2017 11:29 pm

Medicare Question

Post by LITeacher » Thu Oct 04, 2018 6:53 am

Hello!

Here is my mother's predicament that I am hoping you can help me with.

My mother is 65 and retired (my father is retiring on October 31st this year). They are currently on Aetna, my father's health insurance plan through his company, but they are going on Medicare after 10/31 when he is fully retired.

My mom just had a knee replacement two weeks ago (using Aetna as the insurance provider) and went to rehab for 7 days (her last knee they paid for 3-4 weeks of rehab in-patient, but now they only cover a week). It turns out, she was sent home after the 7 days but was definitely not ready because she ended up falling three days ago and last night had a revision surgery. She tore her MCL this time so it was a more difficult surgery, and she now is not able to bend the leg for 6 weeks and will therefore need much more care around the clock until her brace comes off.

My aunt has Medicare, and Medicare allowed her to stay at the inpatient rehab facility for four weeks with a similar surgery, so my question is...

Is my mother able to drop Aetna and get onto Medicare before 10/31? Is there anyway to expedite this process so that she can go to inpatient rehab under Medicare as the provider? Would her knee be a preexisting condition and therefore not covered by Medicare at all or is the fact that there is no underwriting the first time you get Medicare + Supplement mean they have to cover it?

Any help you can give is greatly appreciated, but we are trying to see what our options are without laying out $300 a day for someone to help her in the house.

Just an edit: She already filled out the paperwork for Medicare to start after 10/31, so this is a question of whether it would be possible to move that date up earlier so that the inpatient rehab is covered.

magazinewriter
Posts: 314
Joined: Mon Apr 19, 2010 11:39 am

Re: Medicare Question

Post by magazinewriter » Thu Oct 04, 2018 8:37 am

Others will have more details, but my understanding is that Medicare will only pay for inpatient rehab directly after a three-night hospital stay. So I don’t believe your mom will qualify even if she takes Medicare early. Plus, since it is already October I don’t see how she could get Medicare this month.

Good luck. I understand about an elderly parent falling. Could a family member stay with her temporarily?

LITeacher
Posts: 58
Joined: Mon Aug 07, 2017 11:29 pm

Re: Medicare Question

Post by LITeacher » Thu Oct 04, 2018 9:10 am

Just clarifying, she is in the hospital right now due to the revision surgery and will be there 3 days. Aetna will cover 7 days In patient rehab for this which would start on Sunday.
Last edited by LITeacher on Thu Oct 04, 2018 9:12 am, edited 1 time in total.

cashmoney
Posts: 178
Joined: Thu Jun 29, 2017 11:15 pm

Re: Medicare Question

Post by cashmoney » Thu Oct 04, 2018 9:10 am

LITeacher wrote:
Thu Oct 04, 2018 6:53 am
Hello!

Here is my mother's predicament that I am hoping you can help me with.

My mother is 65 and retired (my father is retiring on October 31st this year). They are currently on Aetna, my father's health insurance plan through his company, but they are going on Medicare after 10/31 when he is fully retired.

My mom just had a knee replacement two weeks ago (using Aetna as the insurance provider) and went to rehab for 7 days (her last knee they paid for 3-4 weeks of rehab in-patient, but now they only cover a week). It turns out, she was sent home after the 7 days but was definitely not ready because she ended up falling three days ago and last night had a revision surgery. She tore her MCL this time so it was a more difficult surgery, and she now is not able to bend the leg for 6 weeks and will therefore need much more care around the clock until her brace comes off.

My aunt has Medicare, and Medicare allowed her to stay at the inpatient rehab facility for four weeks with a similar surgery, so my question is...

Is my mother able to drop Aetna and get onto Medicare before 10/31? Is there anyway to expedite this process so that she can go to inpatient rehab under Medicare as the provider? Would her knee be a preexisting condition and therefore not covered by Medicare at all or is the fact that there is no underwriting the first time you get Medicare + Supplement mean they have to cover it?

Any help you can give is greatly appreciated, but we are trying to see what our options are without laying out $300 a day for someone to help her in the house.

Just an edit: She already filled out the paperwork for Medicare to start after 10/31, so this is a question of whether it would be possible to move that date up earlier so that the inpatient rehab is covered.



There would be no underwriting and pre ex would be covered from the 1st day per the guarantee issue rules for medicare supplement as long as the skilled nursing care stay started after 11/1 If switching to a MA plan there is never underwriting or pre ex waiting periods so this isn't an issue as long as the SNF is in the network. Something else to consider is that under original medicare she may have to be re-emitted to the hospital for at least 3 days before medicare will pay whereas MA plans generally do not have this stipulation

pintail07
Posts: 351
Joined: Fri Nov 04, 2016 5:07 pm

Re: Medicare Question

Post by pintail07 » Thu Oct 04, 2018 1:44 pm

Get a copy of the policy or a summary of benefits. Read the section regarding in patient rehab. Many of these plans offer 60 days as the benefit.

dennisbyron
Posts: 44
Joined: Wed Mar 22, 2017 5:21 am

Re: Medicare Question

Post by dennisbyron » Sat Oct 06, 2018 7:46 pm

LITeacher wrote:
Thu Oct 04, 2018 6:53 am
Hello!

Here is my mother's predicament that I am hoping you can help me with.

My mother is 65 and retired (my father is retiring on October 31st this year). They are currently on Aetna, my father's health insurance plan through his company, but they are going on Medicare after 10/31 when he is fully retired.

My mom just had a knee replacement two weeks ago (using Aetna as the insurance provider) and went to rehab for 7 days (her last knee they paid for 3-4 weeks of rehab in-patient, but now they only cover a week). It turns out, she was sent home after the 7 days but was definitely not ready because she ended up falling three days ago and last night had a revision surgery. She tore her MCL this time so it was a more difficult surgery, and she now is not able to bend the leg for 6 weeks and will therefore need much more care around the clock until her brace comes off.

My aunt has Medicare, and Medicare allowed her to stay at the inpatient rehab facility for four weeks with a similar surgery, so my question is...

Is my mother able to drop Aetna and get onto Medicare before 10/31? Is there anyway to expedite this process so that she can go to inpatient rehab under Medicare as the provider? Would her knee be a preexisting condition and therefore not covered by Medicare at all or is the fact that there is no underwriting the first time you get Medicare + Supplement mean they have to cover it?

Any help you can give is greatly appreciated, but we are trying to see what our options are without laying out $300 a day for someone to help her in the house.

Just an edit: She already filled out the paperwork for Medicare to start after 10/31, so this is a question of whether it would be possible to move that date up earlier so that the inpatient rehab is covered.
Wow, find a SHIP volunteer in your county... at a senior center or Area Agency on Aging or some group like that.

I think it's too late for her to get on Medicare this month but or because it sounds like she is already on it for sure starting November 1. This is the US Government we are talking about here...

If they are both on Medicare as of November 1, have they picked a supplement or signed up for a public Part C health plan yet also effective November 1? (Oh, I assume the about to be former employer does not offer any retirement plan.)

Medicare does not allow any specific amount of rehab... goes by a medically necessary rule. Like Aetna it tries to keep the length of time low. But no one has just Medicare (see question above)

There is no pre-existing condition issue vis a vis Medicare but there might be with a private supplement depending on where you live because the private supplements are regulated by state. Probably not but you have too many moving parts to depend on any answer you might get here. Go find someone who knows the local rules

Spirit Rider
Posts: 8693
Joined: Fri Mar 02, 2007 2:39 pm

Re: Medicare Question

Post by Spirit Rider » Sat Oct 06, 2018 8:04 pm

When was she 65?

Upon enrollment, Medicare part A coverage is automatically retroactive up to six months, but not before age 65.

ChrisC
Posts: 696
Joined: Tue Jun 19, 2012 9:10 am
Location: North Carolina

Re: Medicare Question

Post by ChrisC » Sat Oct 06, 2018 8:59 pm

Spirit Rider wrote:
Sat Oct 06, 2018 8:04 pm
When was she 65?

Upon enrollment, Medicare part A coverage is automatically retroactive up to six months, but not before age 65.
Yes, that might be true but the cost of knee replacement surgery and rehab isn't entirely borne by Medicare Part A. She might get up to 100 days of in-patient coverage for the hospital stay under Part A, but not sure all of the rehab/therapy, medications etc will be covered under Part A, which still has a deductible, for the hospital stay. I've had to deal with the Medicare Summaries for 5 knee replacement surgeries (BIL for 2 and DW for 3) and rehab/ and physical therapy and both Parts A and B are implicated.

I'm curious about whether she receives her own SS retirement benefits and, if so, why wasn't she automatically enrolled in Part A and B when she turned 65.

There' might be more than meets the eye here.

LITeacher
Posts: 58
Joined: Mon Aug 07, 2017 11:29 pm

Re: Medicare Question

Post by LITeacher » Wed Oct 10, 2018 9:41 pm

ChrisC wrote:
Sat Oct 06, 2018 8:59 pm
Spirit Rider wrote:
Sat Oct 06, 2018 8:04 pm
When was she 65?

Upon enrollment, Medicare part A coverage is automatically retroactive up to six months, but not before age 65.
Yes, that might be true but the cost of knee replacement surgery and rehab isn't entirely borne by Medicare Part A. She might get up to 100 days of in-patient coverage for the hospital stay under Part A, but not sure all of the rehab/therapy, medications etc will be covered under Part A, which still has a deductible, for the hospital stay. I've had to deal with the Medicare Summaries for 5 knee replacement surgeries (BIL for 2 and DW for 3) and rehab/ and physical therapy and both Parts A and B are implicated.

I'm curious about whether she receives her own SS retirement benefits and, if so, why wasn't she automatically enrolled in Part A and B when she turned 65.

There' might be more than meets the eye here.
Sorry for responding so late. My mom is 65 (turned it on April 23) and collects social security already. My dad however is working until 10/31 so they are still on Aetna, my dad’s plan at his job (which is free for them-covered in full by his employer). Her supplement plan starts November 1. Is she covered in Aetna and Medicare Part A simulataneously? Would Medicare Part A cover this knee revision surgery or Aetna?

Spirit Rider
Posts: 8693
Joined: Fri Mar 02, 2007 2:39 pm

Re: Medicare Question

Post by Spirit Rider » Wed Oct 10, 2018 10:06 pm

If your dad's employer has > 20 employees, Aetna would be primary and Medicare secondary.

Depending on any Aetna plan deductible, co-pay and/or co-insurance plus how much any residual amounts might be Parts A and B and whether she had her own Medicare Supplement plan, will determine how much if any patient responsibility.

LITeacher
Posts: 58
Joined: Mon Aug 07, 2017 11:29 pm

Re: Medicare Question

Post by LITeacher » Wed Oct 10, 2018 10:10 pm

Spirit Rider wrote:
Wed Oct 10, 2018 10:06 pm
If your dad's employer has > 20 employees, Aetna would be primary and Medicare secondary.

Depending on any Aetna plan deductible, co-pay and/or co-insurance plus how much any residual amounts might be Parts A and B and whether she had her own Medicare Supplement plan, will determine how much if any patient responsibility.
It is greater than 20 employees. A site I just read said: “Medicare Part A reimburses stays at an inpatient rehabilitation facility in the same way as it reimburses regular hospital stays; in other words, you will have the same out-of-pocket costs. Accordingly, Medicare pays only certain amounts of your stay at an IRF. For the first 60 days you are an inpatient in an IRF, Part A hospital insurance pays for everything.”

So if Aetna only gives her 8 days of coverage for inpatient rehab, wouldn’t Medicare Part A pick up the next 52 days?

chemocean
Posts: 47
Joined: Mon Dec 19, 2016 9:45 pm

Re: Medicare Question

Post by chemocean » Wed Oct 10, 2018 10:43 pm

The issue with the previous authorization after 3 days of hospitalization is that Advantage Part C insurers gets to decide when Skilled Nursing Rehabilitation is no longer "medically necessary" as primary insurer. You can ask for an expeditated Level 1 appeal to continue skilled nursing coverage, performed by a third party picked by the Advantage plan, which might get you a couple extra days during the appeal if unsuccessful. If you leave skilled nursing, the issue is moot because you can't ask for reimbursement for skilled nursing that you SHOULD have had. If you stay in the facility as a private pay, you can ask for a Level 2 Appeal, the decision again being decided by a third party picked by the Advantage plan to get reimbursed for the extended rehab period, by appeal. A case manager said she has only seen reversals of coverage of skilled nursing services happen four times in her 16 year career. Only when you get to the Level 3 Appeal, do you appear before a Medicare Hearing Examiner.

In contrast, if you have Traditional Medicare, the skilled nursing facility, which probably wants the patient to reach their full recovery potential, decides when rehab is no longer medically necessary. Medicare usually accepts the recommendation of the skilled nursing facility. You can have other insurance that will coordinate benefits with Medicare as a secondary insurer to pay some of the co-pays and deductibles, BUT NOT MEDICARE ADVANTAGE PART C plans.
My understanding is that if you switch plans, any treatment that you are undergoing at the switch will be paid by Medicare under the rules of the plan that were in affect when you started the treatment. Advantage Part C plans have many advantages, but being treated fairly related to skilled nursing services under Part A after hospitalization is not one of them. As mentioned earlier, you can always switch out of the Medicare Advantage Part C plan to Traditional Medicare, with some short processing period, but coverage by a private secondary insurer is not guaranteed. If you belong to a group plan that provides secondary coverage, you might have to wait until the open enrollment period to switch to Traditional Medicare as primary and your group coverage as secondary.

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