MDS/LTC nurses, need help re: RAP

Long Term Care Columnist / Guide · Nov 4, 2004

If your mother was sent to the facility for Skilled nursing services, they do Medicare assessments at 5, 14, and 21 days with RAPS due by midnight of the 21st day. Usually, however, facility staff can determine within that first 5 days whether continued 'skilled' care is necessary, which doesn't seem to be appropriate in your mother's case. That is when they are supposed to issue the resident and family a 72-hour notice of denial of SNF care, which has a grace period in which the decision can be appealed.

It sounds like you never received such notice. (Your mother's dementia, however, does qualify her for intermediate level care, but Medicare doesn't pay for it......which means either paying privately or applying for Medicaid.) In your place I would first retain the services of a good attorney who specializes in elderly issues (Medicare, LTC, estate planning etc.) and then apply for Medicaid. If there are assets, you'll probably have to 'spend down' until there's less than $2,000 (may be different in some places?) liquid assets, meaning cash or anything that can be converted to cash. It stinks, I know........hopefully you can get a good lawyer to help you straighten all this out.

Also....you'll want to get in touch with your local Senior & Disabled Services agency (it's called different things in different parts of the country, but they all have federal and/or state funding). Check the government pages in your phone book. They are enormously helpful in assisting people with elder-care concerns, and they'll be very interested in finding out why your mother's facility didn't go by the book in letting you know about her change in status.

Best of luck to you.

fluffwad · Nov 4, 2004

first, was your mother in the ltc under part a medicare coverage? or was she managed care? did she get physical therapy/ occupational therapy?

if she was part a medicare, she only gets a max of 100 days part a coverage...but coverage continues only as long as she is progressing/ or there is a "skilled" need - as defined by medicare regulations. when she stops making progress, part a coverage stops (whether or not you've gone to 100 days). the rap is only one bit of the mds document that someone might looks at to determine the whole of the picture.

there is a section that covers mental status......but having memory loss, etc doesnt qualify you for medicare part a coverage.

if there are no funds available....does she qualify for medicaid? if she does need to be in a nursing home permanently, this may mean selling her house if she has one....before she'll qualify. there should be someone there ( the social worker) who can answer that.

i'd need more specific info before i can tell you much more than this.

sunnybrook83 · Nov 6, 2004

Initially, she was placed for continued rehab, and when that was no longer needed, we did receive the notification of no further medicare payment and made the appropriate app to medicaid. Did the spend down, etc... but because the home did not get the info in on time, it has been initially denied- am in the appealing process. But they (the home) are telling us that because mom can walk, she'll be denied by the physician review board, despite the fact that she has dementia. She is oriented half the time to place and person, time is variable. But to events, nada. You can visit her in the am, and if someone asks in the afternoon if anyone's been in to see her, she says no. Is not capable of self medicating due to this condition (the reason we had moved her in with family prior to the cva). She doesn't even recall having had a stroke or being in the hospital. Due to work, families, etc... no family member is able to care for her at home, and I have my doubts about the safety of that anyway. She's off balance at times in gait, doesn't eat, dress, wash, etc... unless specifically directed, and has mood swings. If you can provide any more input, I'd greatly appreciate it.

Thanks for your help so far!!

fluffwad · Nov 6, 2004

I don't know, this scenario doesnt sound right. I've got Medicaid covered patients who sound just like this. If you think the person at the nursing home doesnt have all his /her ducks in a row, you can talk to the local medicare/medicaid agency, and / or the omsbudsman. That's what they are there for......the bit about having the paperwork in on time concerns me. A chat with the nursing home's administrator might be interesting.

You might also consider a different NH if you think this one is jerking you around.

ADON132 · Nov 7, 2004

I would not go to the expense of getting an attorney, I have been doing admissions under Medicaid for 16 years and I've never seen a person denied Medicaid that fits the description that you gave of your mother. But than again I live in KY and it may be different in your state.

sunnybrook83 · Nov 12, 2004

Thanks for all your input. We did end up transferring mom to a home in a neighboring state. The new home said can't believe mom would be denied in the original state, that they will have no problem getting her qualified. so her future is settled (I hope). Now, we just have to fight with the old home to get the correct assessment sent in so the bills there will be taken care of.

(And so help me, if it comes back approved from the original state, I'll have to have a temper fit at the old home just for putting us through this!! :uhoh3: )

Thanks again!!!