Center for Medicare Advocacy
(November, 2013 Update)
Late November is often a time for gatherings with family and friends – Thanksgiving and Hanukkah, soon followed by Christmas and the New Year. Nursing home residents often want to participate in these gatherings but may worry that they will lose Medicare coverage if they leave the facility to do so. Residents and their families can put their minds at ease. According to Medicare law, nursing home residents may leave the facility for holidays without losing their Medicare coverage. However, depending on the length of their absence, beneficiaries may be charged a “bed hold” fee.
The Medicare Benefit Policy Manual recognizes that although most beneficiaries are unable to leave their facility,
“an outside pass or short leave of absence for the purpose of attending a special religious service, holiday meal, family occasion, going on a car ride, or for a trial visit home, is not, by itself evidence that the individual no longer needs to be in a SNF for the receipt of required skilled care.”
A facility should NOT notify patients that leaving the facility will lead to loss of Medicare coverage. The Medicare Benefit Policy Manual says that such a notice is “not appropriate.”
If the resident begins a leave of absence and returns to the facility by midnight, the facility can bill Medicare for the day’s stay. If the resident is gone overnight (i.e., past midnight) and returns to the facility the next day, the day the resident leaves is considered a leave of absence day. Clarifying what seemed to be conflicting provisions in the Manuals, the Centers for Medicare & Medicaid Services (CMS) confirms that the facility can bill a beneficiary for bed-hold days during a SNF absence.
Chapter 6 of the Medicare Claims Processing Manual provides that the facility cannot bill a beneficiary during a leave of absence, “except as provided in Chapter 1 of the manual at §22.214.171.124.” That section authorizes skilled nursing facilities (SNFs) to bill a beneficiary for bed-hold during a temporary “SNF Absence” if the SNF informs the resident in advance of the option to make bed-hold payments and of the amount of the charge and if the resident “affirmatively elect[s]” to make bed-hold payments prior to being billed. Charges to hold a bed and maintain the resident’s “personal effects in the particular living space…are calculated on the basis of a per diem bed-hold payment rate multiplied by however many days the resident is absent, as opposed to assessing the resident a fixed sum at the time of departure from the facility.” CMS distinguishes bed-hold payments from payments for admission or readmission, which are “not allowed.”
Residents can leave their SNFs for short periods, such as a day or two, to enjoy the holidays with their families and friends without losing Medicare coverage. Their SNFs are, however, allowed to bill them to hold their beds under Medicare rules.
For more information, contact attorney Toby S. Edelman (email@example.com) in the Center for Medicare Advocacy’s Washington, DC office at (202) 293-5760.
I love that researchers are more engaged in the pursuit of Happiness. It seems like a no-brainer, but there was a time, not so long ago, that the roots of happiness were believed to dwell somewhere deep beneath a wounded unconscious. Painful excavation was considered necessary to discover and eject the demons responsible for igniting individual and collective angst. The “proof” of a positive relationship between happiness and gratitude offers profound hope to seekers. Punitive superego: move over. We can actually get there from here!
Co-Investigators Robert A. Emmons, University of California, Davis and Michael E. McCullough, University of Miami are engaged in a long-term research project, inquiring into the nature of gratitude and thankfulness and its impact on health and wellbeing.
They found that grateful people report higher levels of positive emotions, life satisfaction, vitality, and optimism and lower levels of depression and stress. Grateful people do not deny or ignore the negative aspects of life. Gratitude appears to enhance pleasant feeling states more than it diminishes unpleasant emotions.
The researchers also note that those strongly disposed toward gratitude have the capacity to be empathic and to understand the point of view of others. People in the social networks of those that are grateful are rated as more generous and more helpful by others (McCullough, Emmons, & Tsang, 2002).
There is huge value in “practicing” gratitude in concrete ways, thus becoming more aware of blessings. Keeping a gratitude journal on an at least weekly basis by taking just a few minutes to list those things for which one is grateful had a significant impact upon study participants. They reported more regular exercise, fewer physical symptoms, feeling better about their lives overall, and were more optimistic in the following week compared with those who recorded problems and stresses, or neutral life events (Emmons & McCullough, 2003).
A related benefit was observed in the realm of personal goal attainment: Participants who kept gratitude lists were more likely to have made progress toward important personal goals. Gratitude also translated into decreased envy and materialism!
I think most profound and important is a major Kumbayah factor: the finding that grateful people are more likely to acknowledge a belief in the interconnectedness of all life and a commitment to and responsibility to others (McCullough et. al., 2002). (!)
The happy fruits of gratitude are borne through mindfulness: becoming conscious and attentive to the blessings in your life. This Thanksgiving begin the lucrative practice of creating a list of blessings for which you are grateful. Then at least weekly take a little time to focus on the abundance in your life by continuing to journal simple lists. And breathe deeply. And celebrate.
“Both abundance and lack exist simultaneously in our lives, as parallel realities. It is always our conscious choice which secret garden we will tend… when we choose not to focus on what is missing from our lives but are grateful for the abundance that’s present — love, health, family, friends, work, the joys of nature and personal pursuits that bring us pleasure — the wasteland of illusion falls away and we experience Heaven on earth.” –Sarah Ban Breathnach
Happy Thanksgiving from Monica, Judy, Susie, Trish, Gwen, Gabe, Brooke, Glen and Scout!
To all of the men and women currently serving and to the many veterans who proudly and honorably served, we salute you. To all of the families who have lost loved ones in battle, we remember you and thank you for the service that was given. Veteran’s Day only lasts a short time, but our gratefulness does not end. Thank you!
In honor of the day, we compiled some links and websites related to Veteran’s Day. To learn more about its history, go here.
There are some fantastic organizations working with our veterans. See the links below to learn more about the programs and how you may be able to help.
For services for veterans, the US Dept of Veteran’s Affairs and the State of Tennessee Office of Veteran’s Affairs are fantastic resources. The State of Tennessee Office of Veteran’s Affair office in Knoxville is where we recommend clients visit when applying for Aid and Attendance. Contact our office if you have any questions about how these resources might fit into your Life Care Plan.
Freebies and Fun
Many stores and restaurants offer discounts or freebies for military men and women and veterans. For a listing of some of these great deals, go to Real Housewives Clip Coupon’s blog post here. If you are looking for a fun activity for today, consider attending the Knoxville Veteran’s Day Parade.
Thank you to our veterans! God Bless our great United States of America!
With Daylight Savings Time “Fall Back” arriving soon, now is a good time for a reminder of the importance of fall prevention. In Knox County, more than 1,800 people aged 65 and older sought hospital care for falls in 2009 (the most current data), and approximately 19 people aged 65 or older die each year from their injuries. The CDC estimates that 1 in 3 older adults fall each year but only half talk with healthcare providers about it. Falls are the leading cause of fatal and nonfatal accidents in older adults, with around 2.3 million falls treated in the ER in 2010.
Not only are falls affecting the health of older adults, they are also affecting their pocketbooks. In 2006, the direct medical cost of fall related injuries in older adults was $20 billion, and this number has risen with inflation and the aging of the Baby Boomer generation. While Medicare and other supplemental insurances cover part of that cost, out of pocket medical expenses are many times a burden on the elderly and their caregivers. After falls, elderly often see a decline in independence and may need personal care attendants or assisted living services, neither of which is covered by medical insurance.
What can be done?
Benjamin Franklin once said, “An ounce of prevention is worth a pound of cure,” and this quote can also apply to fall prevention. Take these steps to help reduce your risk:
Imagine this scenario. Your father falls in the bath and is raced to the hospital. The ER doctor says that a bone is broken and he will be moved upstairs for a few days. Three days later, you meet with the discharge planner and ask about skilled rehabilitative care. The discharge planner surprises you by saying that your father is not eligible for Medicare payment of skilled care because he was never admitted to the hospital. “There must be some mistake. He has been on this hospital floor for three days.” She responds, “He was on the floor for observation. It is different from being admitted, and therefore Medicare won’t pay for treatment at a skilled nursing facility.”
This scenario has become more common in recent years as Medicare has become more stringent with hospitals over admission criteria, especially for shorter lengths of stay. The American College of Emergency Physicians explains:
With short inpatient hospital stays (less than the average LOS) Medicare is concerned about overpayment and appropriateness of the admission. As a result, Medicare and a state’s Quality Improvement Organization (QIO) monitor hospital discharge data and specifically target short hospital stays.
If a hospital is found to have a high frequency of short inpatient hospital stays Medicare will investigate and if inappropriate admissions are found the sanctions can be severe. As a result, hospital health information management (HIM) and utilization management (UM) staff closely monitor the medical necessity of inpatient hospital admissions and short inpatient hospital stays. Their efforts can put pressure on emergency department physicians to make sure that each inpatient admission from the [emergency department is] medically necessary and will pass fiscal intermediary or Medicare Area Contractor (MAC) scrutiny.
In some cases the use of observation status might be an alternative to an immediate inpatient admission.
Why does this matter?
Medicare will only pay for skilled nursing care after a person has been admitted to the hospital for three midnights. If faced with a decision to pay out of pocket for skilled care (to the tune of thousands of dollars) or to forego treatment, many choose the latter option placing them at a higher risk for re-hospitalization. They are still eligible for home health, but home health care does not provide the intensity and frequency of therapy seen in skilled nursing facilities.
Skilled care is offered on a separate hospital floor or inside a nursing home, which has the added benefit of providing day-to-day care while undergoing therapy. If not receiving skilled care, extra help may be needed for your loved one either through informal assistance from family members and friends or through paid services such as sitters, assisted living care, or long term care at a nursing home.
Cost of hospitalization is another important issue. While observational care may look and feel like a hospital admission, it is billed differently and that difference can mean a hefty bill at the end of treatment. The Centers for Medicare and Medicaid Services explain:
As a consequence of the classification of a hospital stay as outpatient observation (or of the reclassification of a hospital stay from inpatient care, covered by Medicare Part A, to outpatient care, covered by Medicare Part B), beneficiaries are charged for various services they received in the acute care hospital, including their prescription medications. They are also charged for their entire subsequent [skilled nursing facility] stay, having never satisfied the statutory three-day hospital stay requirement.
So what can you do?
Sent from somewhere to my soul
How they linger, ever near me
And the sacred past unfolds.
J.B.F. Wright 1925
This time of year inspires its own unique reverie, brought on by a subtle but unmistakable change in the light heralding summer’s end. There’s a mix of melancholy and anticipation which creeps into the psyche, as the child in each of us stirs. I personally believe The School Calendar is irretrievably encoded at some deep molecular level in our DNA, and that the collective unconscious is home to that mysterious urge to buy a new outfit, or big red pencils in a pretty box each August.
With the first early morning sighting of a blinking yellow light chiding us to pay attention, we realize where that little ache was coming from: it’s back to school time! And with a sigh, a chuckle or perhaps a shudder we recall some of our own “first days.”
The memories that most readily come to mind tend to be The Best and The Worst. Happily, in the sweet light of retrospection, the Best get better, and so the do the Worst! We have become more tolerant, more compassionate, and more appreciative with the passage of time. Those “I do know now what I didn’t know then” insights enable us to reframe the unhappy into character building experiences, or simply to shrug and feel relief that those times are done, and that we survived and yes, even thrived.
Such reminiscing is not “living in the past.” Mostly, our memories provide a safe network of trails to past triumphs and traumas. Those reflections supply important opportunities to integrate experiences, celebrate strengths and successes, reconcile conflicts and ultimately to feel okay about things, past and present. Talking therapies have long focused on using insights from the past to better manage the present through reminiscing. In that forum, “letting go” of a troubling, or otherwise dysfunctional past may be the ultimate goal. Equally as important as working through life’s bad stuff is celebrating the good.
For older adults, and especially those with dementia, reminiscing is a powerful tool for making connections with others, for supporting self esteem, and a sense of self- “ego integrity.” Sometimes it is the only tool. No matter that the time or the tale is fleeting. There is still great benefit to participants when stories are heard and valued.
Sight, hearing, smell, taste and touch provide countless ways to reach out to cognitively impaired elders in a manner that honors them and supports their dignity and wholeness. Sharing photographs, music, special foods, and so many more activities help to access important past life experiences. I ran across a study recently that found that reminiscing about shared laughter increased relationship satisfaction! [Bazzini et al; 2007] This research fully supports my firm belief that we should all reminisce about more funny stuff! The study was actually focused on romantic couples, but I think the findings are entirely generalize-able.
Reminiscing is as easy as saying “Tell me about…” We like to tell our stories. We need to tell our stories. It is important for us to tell our stories. Our journeys to wholeness are found in our stories, including our many “first days.”
Someone with dementia may only give you a small piece of themselves — all there is, and enough, at that moment. That small piece is precious and may become a strand or thread woven into your life as well. The fragments may, like the creation of a mosaic, gradually be pieced together and something new is created. (Coaten, 2001, p 21)
Speaking as one steeped in the challenges of everything Alzheimer’s I am excited about our upcoming program, and hopeful that it will be well attended. Is that about raising plenty money for Alzheimer’s Tennessee to improve care for patients? Well, yes, it is. But first and foremost I believe the material we plan to share will help Alzheimer’s patients, their families and professionals providing care and guidance in the field.
In many ways “caregiver training” is in truth a day in, day out revelation for families. Mostly, we do not assume the role with great preparation and experience. In fact, we find ourselves hoping against hope that this whole progressive dementia diagnosis deal is some big ol’ mistake.
Each day and every stage of the disease reveals new, uncharted territory for patients and families. We will begin our morning with a discussion of what happens in the brain and how that translates to the person as Alzheimer’s disease runs its course from the early to the late stages. Given that context and framework we will look at the range of legal needs: what, why, and when.
Anyone who has any experience with Alzheimer’s knows that just because one has carefully gotten all one’s legal ducks in a row does not necessarily mean that those ducks will waddle accordingly! We will discuss the legal tools needed to manage care during the course of the illness, and strategies for managing those loose ducks!
How much “power” does a power of attorney really have? The answer may surprise you! What elements are crucial for inclusion in this document? Is it ever “too late” to appoint a Power of Attorney or make a Will? And what happens when the Power of Attorney is revoked?
What does the family do when the Alzheimer’s patient refuses to follow medical advice? Or financial advice? Or legal advice?
Dealing with self neglect, predators, and the (huge!) driving question are just a few of the many issues we will cover.
As the disease progresses care needs increase. Finding and paying for care, and preserving resources for the well spouse and for future generations will be addressed in our discussion. Finally, we will discuss end of life issues for Alzheimer’s patients, including advanced directives and Living Wills and the use of Comfort Care and Hospice resources.
The idea of planning for incapacity seems counter-intuitive. Or oxymoronic…is that a word? By any name, the process of planning for future disability requires a level of acceptance and insight that may escape some of those suffering the illness, and some of those who are supposed to know better and be tending to this business. Take comfort in the fact that this is a natural response for all to an illness that does “take prisoners.” It is our goal to provide information that will empower patients, families and professionals in their fight against Alzheimer’s and for those affected!
Alzheimer’s is a degenerative brain disease affecting 1 in 10 Tennesseans over 65 and fully half of those who are over 85 years of age. The disease affects not just memory, but also written and spoken language, and the ability to plan, reason and problem solve. As the disease progresses, personality and behavioral changes occur and functioning declines. Family caregivers are faced with significant challenges regarding decision making and care for loved ones unable to care for themselves.
Elder Law Attorney Monica Franklin has been working with Alzheimer’s patients, their families, and caregivers for ten years. With her team of Elder Care professionals, associate attorney, and legal assistants she has worked through many of the questions and challenges this disease presents.
“Alzheimer’s Disease: The Legal Guide” is an important program designed to empower families and healthcare professionals with the legal knowledge and tools to support the best care and quality of life for those with this illness. The three hour seminar will present information relating to the legal issues in the early, middle, and late stages of the illness including:
The seminar will raise monies to fight Alzheimer’s and support better care for patients.
Scheduled for May 5, 2012 from 9 am to 12 pm, the program will be held at Parkwest Hospital.
A tax deductable donation of $25/ person or $40/ couple for Alzheimer’s Tennessee is the cost of admission. Contact hours for professional attendees will be available. Seating is limited.
For more information and to reserve your place, contact the Elder Law Practice of Monica Franklin at 865-588-3700.
“Families struggle with how to ‘do the right things’ for their loved ones at every stage of this disease. Balancing individual rights and wishes with safety, health and financial considerations is a daunting task. Our goals are to help folks to plan and effectively problem-solve, advocate and act as the disease progresses.” – Monica Franklin.