Keep your Medicare clients out of skilled care purgatory

Mitigating Medicare coverage gaps can keep your clients out of what Chelan Jackson calls “skilled care purgatory.”

Jackson, key accounts specialist and compliance officer with Senior Marketing Specialists, spoke during a recent event, “Don’t Be Scared of Long-Term Care” by the National Association of Insurance and Financial Advisors’ Limited and Extended Care Planning Center.

What leads to skilled care purgatory, Jackson said, is Medicare’s “three midnight rule.” Medicare covers skilled nursing care in limited cases, with one condition being that the patient must, in general, have spent three midnights on inpatient status in a hospital. Other qualifications for Medicare coverage of skilled care include the patient’s doctor agreeing that the patient needs daily skilled care by trained staff, and that care is needed for a hospital-related condition or a condition that develops while receiving care for one, and that the care must be given at a Medicare-certified facility.

The No. 1 hurdle for receiving Medicare coverage for care is the inpatient status for three midnights in a hospital, Jackson said. Patients frequently are admitted to a hospital for observation and not inpatient status, and that can lead to a costly surprise if the patient needs skilled care after being discharged from the hospital.

“Talk to your clients about how to make sure they properly advocate for themselves if they are hospitalized to make sure they qualify for the benefits they deserve,” he said.

The consequences of landing in skilled care purgatory can be costly, he said. In general, a Medicare beneficiary will pay nothing for the first 20 days of approved care. The beneficiary will pay $200 a day for days 21-100 with Medicare picking up the rest. But on Day 101 and forward, the beneficiary will be responsible for all the costs of care.

“One of the biggest challenges I see is when care does or should end,” Jackson said. “When a patient plateaus, that’s when you frequently see that patient being discharged.”

In addition, he said, Medicare Advantage and Medicare Supplement differ in how often a patient is assessed as to how their condition will either improve or deteriorate. Some Medicare Advantage plans use predictive modeling to administer skilled care claims without looking at the patient’s medical record or establishing a care plan that makes sense based on that individual’s condition. This also results in shorter stays.

Home health care is a great option for some people, Jackson said, but Medicare coverage of home health care is limited.

Medicare does not cover custodial care, but may cover home aide services, he said. Approval requires a face-to-face visit with a health care provider as well as a determination that a patient faces difficulty or danger in traveling for care. A patient also must qualify for fewer than eight hours of care a day and fewer than 28 hours of care a week.

“The biggest mistake that people make is thinking home care is a good substitute for skilled nursing care – it’s not a total replacement for in-facility care,” he said.

One of the best ways to protect your clients, Jackson said, is to talk to health care providers.

“Talk to doctors, nursing homes, home health agencies. Ask the clients your clients will ask. Not only will it help you build relationships and help clients get coverage, it will also allow you to better understand the rates in your area and how much coverage to write. Talk about care plans with doctors who specialize in geriatrics. The care plan is the biggest and most critical piece to getting care for clients.”

Jackson gave the following advice in finding care solutions for clients.

• Consider short-term care options.
• Find solutions that fit around a client’s current coverage.
• Look at niches in underwriting.
• Take a hard look at overbuying coverage now. When overbuying, make sure you help a client select a policy that will follow them for life.

Susan Rupe is managing editor for InsuranceNewsNet. She formerly served as communications director for an insurance agents' association and was an award-winning newspaper reporter and editor. Contact her at [email protected]. Follow her on Twitter @INNsusan.

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Susan Rupe is editor in chief, magazine, for InsuranceNewsNet. She formerly served as communications director for an insurance agents' association and was an award-winning newspaper reporter and editor. Contact her at [email protected].