Over the years, we've received a number of questions about coverage. The following story was shared recently by Jeanne from New Jersey.  As you can see from Jeanne's situation it can get really complicated really fast.  Jeanne did all the right things: filed an appeal, called her insurer, met with local volunteers (SHIP) and called Medicare.  As we explore her situation, there are a number of questions that need to be addressed.

What type of insurance coverage did your mother have - Medicare Advantage Plan or Medicare Supplement? There are a number of factors that contribute to medical coverage - individual vs. employer sponsored policy (Medicare Only, Medicare Advantage or Medicare Supplement), the state your live in (New Jersey), medical necessity, and Medicare rules.

"My mother is 87.  She was a long time employee of Aetna Life and Casualty in Hartford.  She has lived with me for the past 2 years.  Nine months ago she fell, breaking her hip.  She had surgery and was in rehab for a couple of months.  It was a hassle getting her Aetna Employee Advantage Plan to pay for as much rehab as I thought she needed, and one rehab facility indicated to me that they would not take her because of her plan--said they had had problems with getting Aetna to cover the care which was needed, and indicated it was easier to deal with Medicare than with Aetna. I was very confused because the Medicare and You book states that they will pay for the first 20 days in full, then up to a hundred days at 80% of the cost.  In reality this did not happen.  I filed a quick appeal and lost.  She came home."

Did your mother go to a Rehab Facility or a Skilled Nursing Facility? There are a number of confusing references in the first part of your story.  Inpatient Care in a Rehabilitation Facility is covered under your mother's Medicare Part A Hospital benefit (covered up to 90-days). The physical therapy services she received while in the rehab is covered under your mother's Medicare Part B Medical benefit.  If she only had Original Medicare she would have been responsible for 20% (after paying the Part B deductible).  Since you referenced "20 days" I believe you are describing Skilled Nursing Care. It would be helpful to know which service was provided.

"I agonized long and hard over changing her plan, spoke to Aetna and to Medicare on the phone several times, and met with a SHIP counselor here in New Jersey.  In the end I was still as confused as before.  I would have gladly paid for a private insurance adviser but couldn't find any in the phone book.  In the end I dropped her Aetna plan (they warned me she could never come back to it--why not?  Is it a punishment for dropping them?)"

Have you called the human resource office of your mother's former employer?  It may feel like a punishment and it is intentional. Employer sponsored coverage can be accepted or denied by a retiree. These policies often provide significant benefits to retirees and are subsidized by the employer. When a retiree terminates it represents a significant savings to their employer. Once a retiree terminates their coverage it is usually impossible to enroll again.

"Since January she has had just Medicare with a Humana Wal-Mart Drug Plan. In March (3 mos. ago), she fell again, breaking the same hip. A much worse break this time.  Surgery again, in rehab again.  This time the rehab place tried to evict her after about 6 weeks.  Again I pored over the same confusing info on the Internet, called Medicare and was told they would cover up to a hundred days at 80%, but the rehab place was just as adamant that Medicare would not cover it.  Her personal doctor agreed and said Medicare would not pay.  In the end I wrote a check for $12,000 for her to stay in rehab for a few more weeks. I also feel like I totally screwed my own mother by dropping her Aetna Employee plan.  She has been home for about two weeks now.  Could you advise me about what I should do?  "

Before she came home did the facility send you a notice of non coverage? The rehabilitation center is required under Medicare regulations to give you a notice called an “Advance Beneficiary Notice of Noncoverage” (ABN)  before you reach the 90 day limit for rehabilitation services (or the 100 days of Skilled Nursing Care).  If you should have received an ABN but didn’t, in most cases Medicare will require your provider to refund you for what you paid for the item or service. For more information about ABNs, view the booklet, “Your Medicare Rights and Protections,” or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877486-2048. 

Did you receive a "Medicare Summary Notice" (MSN ) that shows the services provided?  You have 120 days from the date you get the MSN to file an appeal. This might help you recover some of the $12,000. This document lists all the services you received and tells you if Medicare paid for them. Circle the item(s) you disagree with on the MSN, and write an explanation on the MSN of why you disagree. Sign, write your telephone number, and provide your mother's Medicare number on the MSN. Keep a copy for your records. Send the MSN, or a copy, to the Medicare contractor’s address listed on the MSN. You can also send any additional information you may have about your appeal. Or, use CMS Form 20027, and file it with the Medicare contractor at the address listed on the MSN.

"I am thinking of getting her into another Advantage Plan during the next Open Enrollment, but which one?  Aetna won't take her back, and God knows I don't have a very good track record in navigating the system.  My mother is basically healthy other than severe osteoporosis.  She doesn't take any prescription medications on a long-term basis--just daily vitamins, calcium and a stool softener.  I would be most grateful for any advice you could give."

What should you do next? I recommend using the Medicare.gov site and researching Medicare Advantage plans available in New Jersey. Medicare has a 5 Star Rating system that tracks 36 measures for health services and 17 for drug services. The Overall Plan Rating gives you a single summary score that makes it easy for you to compare plans based on quality and performance. It is your choice whether to chose a HMO or PPO.   I recommend sorting the plans available to you in New Jersey by their ranking.  You can choose a plan with or without drug coverage.  Your mother's next opportunity to add coverage starts on Oct 15th and ends on Dec. 7th. There is no rating system for Medicare Supplements, so based on your experience I wouldn't recommend a supplement.

You did all the right things for your mother. I always recommend documenting who you talk to at Medicare (employee name and number), in the community (SHIP) and others.  Generally if you can document that you were misinformed by a federal agent you may have additional opportunities to recover your losses. Your congressman may be able to help as well.  Finding legal counsel is never easy. If you've kept all your documentation you can always contact an attorney like Sokolove to determine if you have a case.

About the Author:

My name is Dana Cutter and I am Founder and Editor of Medicare Sherpa. Our staff spends their days searching the Internet for the best content and advice on retirement.  On our site you will find articles on Social Security, Medicare Benefits,Prescription Drug Benefits and more. Please feel fee to send me an email with ideas for content, site improvements or general help launching your online persona. I hope you will consider joining and I am looking forward to reading more about you online.

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Jeanne June 17, 2011 67.85.64.81 Votes: +0	Thank you for all the time you took in answering this, Dana. Sorry for my delay in responding. I'll try to answer all your questions. My mother had a Medicare Advantage Plan through Aetna. She was in a state licensed skilled nursing facility which also provides rehab services (PT, OT, etc.). In both cases the facility tried to evict her after a few weeks because they said she does not have a "qualifying medical condition" which would entitle her to additional skilled nursing. The words "wound care, diabetes," and "insulin injections" were given as examples. In other words, if she was diabetic, needed help with injections, or care of a festering wound, she would be allowed to stay and receive nursing care. Several weeks after entering, we had a follow up visit with her surgeon, and he said that she was still not allowed to put weight on the injured leg (this was determined through an x-ray). He gave us a date to return to him to see if there was any bone growth; this last time it was four weeks later. The facility had already explained to me that if this happened, Medicare would not pay for her stay, and that I would have to pay. I agreed and signed papers to that effect because I felt I had no choice. I couldn't find a form with the number you mentioned, but the stuff I signed was essentially the same, I think, but the nursing facility's own forms. When we went for the follow-up visit 4 weeks later, the surgeon said it was okay for her to put weight on the leg, and my mother was allowed to resume physical therapy. The second time she had about 10 days of training with a walker, and was allowed to come home. The Medicare Summary Notice does not sound familiar to me--I don't think I received anything like that. You asked if I had called the Human Resources office at Aetna. Why would I do that? They said she could never come back into their plan again (although she still has her dental benefits through them). If I called, what would I say? Thanks for the advice about going onto the Medicare website with the 5 star rating. I have been on it before, but I had totally forgotten about it. Being a caregiver is the most exhausting thing I've ever done, and I feel scattered much of the time. I am not sure I have the energy to file an appeal at this point. I do belong to a support group for caregivers and an Elder Law attorney is speaking to us next week. report abuse vote down vote up

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