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Bill S.

July 16, 2015

I am ... A Caregiver or Family Member

On January 18, 2014 my mother had a devastating stroke. She is paralyzed on the right side and non verbal; in fact, with the exception of feeding herself with her left hand, she is completely dependent on others for her every need. She has been in 4 different facilities in since her stroke. Medicare only gave her 100 days to make a complete recovery. While her doctors all say she is capable of making and "astonishing" recovery, 100 days is not enough; in fact, they say 2 years. One hundred days would be adequate for a knee or hip replacement; or even shoulder surgery, but not a devastating stroke. This should be an exception and NOT a rule. I understand that this was just changed in the last two years and, although Medicare Part B had limits, therapy limits were generally not observed. I am also told that this was changed due to excessive fraud. This may be the case but there were better options that taking away something that actually has benefit. Illinois for example has paid out 12 billion in benefits paid to DEAD people over some period of time; and they are not alone. California and 38 other states all have documented fraud over 1 billion dollars. This would be an easy fix since Medicare and Medicaid are under Social Security. Cross checking SSN’s periodically would NIP a lot of this.

On May 25th, Medicare Part A 100 day benefit period expired. At the time, Physical Therapists had my Mother standing weight baring on both feet with assistance; that was great progress. She continued therapy (all three disciplines) for a few more days until the Medicare Part B caps were met. At that time we had to move my Mother to a new facility since that one did not except Medicaid. She has not had therapy since June 10th and has regressed to the point where she does not even want to get out of bed.

In short Medicare Part A 100 day Benefit period, when it comes to patients like my Mom, is nothing more than a benefit period for death making Medicare guilty of Murder. I find this quite analogous to, if not worse than the VA scandal in the manner that they tease people with recovery by giving 100 days to recover from a devastating stroke and literally pulling the rug out from under these people just when they begin to recover.

Since Medicare ran out and Medicaid is barely in force, we are out 13000.00 for private pay in a local rehab facility. My mother is a retired Federal Employee having spent many years in the DOD. We, she, needs help with her situation in many ways. First of all, Medicare, for as good as it was for 100 days has a major flaw in that it lumps people like my mother into a category of need that is not adequate for their medical situation. THIS NEEDS TO BE CORRCTED. In addition with respect to Medicaid, you cannot apply until you are in a facility that takes Medicaid and you cannot get into a facility that takes Medicaid until you have Medicaid or can afford private pay; and, the process is confusing and takes way to long. This whole Medicare Medicaid process has been a nightmare for me and my family, but, especially my mother.

UPDATE: My Mothers Medicare 100 day Benefit Period ended on May 25th, 2014. It took 11 Months of persistent digging and pushing to get her therapy restored. I fear now that too much time has passed and that she has lost some of her will. She is still paying for Medicare, and has since 1965, but the rules of both Medicare and the facility where she is living made it very difficult in the best of situations to get her what she needed. No one should have to fight so hard for the benefits for which they are entitled and deserve. So, she has paid into Medicare since it was created and all that she gets when she needs it is 100 days to recover from a devastating stroke. This is the same amount of time allotted to someone recovering from Knee surgery.

Another update: While in a nursing home, my Mother caught an infection that was not treated in a timely manner. Her white blood count hit nearly 18,000 (8,000 to 11,000 is normal). She was septic, had a massive heart attack that destroyed two thirds of her heart. She went to hospice and died on June 29, 2015.

I have also drafted and sent a Bill to Congressman Steve Cohen for presentation to Congress for consideration. Please see attached.              

Medicare's 100 Day Benefit Period: What It Means to You and You Need to Know

In 1965, as part of Lyndon Johnson's great society, Congress and the President gave birth to the current Medicare and Medicaid systems. While Medicaid has problems of its own, Medicare is far worse and requires more immediate attention. In my experience over the last year, one thing has become crystal clear; Medicare is designed to let people die if they can not recover in one hundred days. Here is how it works:

  1. After a 3 day qualified stay in a hospital, you are eligible for 100 days of coverage from Medicare including Long Term Care and Therapy.
  2. If you go to the hospital during the first one hundred days for 3 nights, the 100 day benefit period starts all over again.
  3. If you make it through the first 100 days, you enter a 60 day wait period before you qualify for another one hundred days.
  4.  If you go to the hospital for 1 night during that 60 day wait, it starts all over again; even if you are on day fifty-nine.
  5. Once the 60 (or more) day wait is over, you then qualify for another 100 days of Medicare coverage; but, you must be admitted to the hospital for three nights on a qualified stay that CANNOT be related the event that you experienced in the first one hundred day benefit period.

What This Means To Medicare Recipients.

Example 1.

Knee Replacement Surgery

  1. You have knee surgery on January 18th.
  2. You spend 3 nights in the hospital.
  3. You qualify for 100 days of care and therapy; realizing of course that one likely will not need long term care for knee surgery.
  4. After the hospital stay, you begin therapy.
  5. PT for knee surgery (replacement) is intensive for 4 to 6 weeks ( well within the 100 day Benefit period) but the recovery itself can be upto one year.
  6. May 25th, you meet the 100 day deadline but you have finished the covered therapy and made significant recovery.    

Example 2.

Devastating Stroke

  1. You have a devastating stroke on January 18th.
  2. You spend 10 days in the hospital
  3. Transfer to a Short Term Skilled Nursing facility for a 20 day stay at 100% coverage by Medicare during which time intense Physical, Occupational and Speech therapy's ensue.
  4. After 20 days, you transfer to a Long Term Care Skilled Nursing Facility and Medicare pays 80 percent. Therapy continues for the 80 day remainder of the 100 day benefit period.
  5. May 25th, end of the 100 day benefit period. You are just beginning to make good progress in all disciplines of therapy; MEDICARE QUITS PAYING FOR YOUR THERAPY as well as your long term care. You are now MEDISCREWED.

The Bill

United States House of Representatives
113th Congress
2nd Session
H.R. ______________

A Bill

To ensure that the ongoing needs of Therapy and Rehabilitation Medicare Part A recipients are met for those whose needs truly extend beyond 100 day benefit period and to  provide for categorization of such needs there by eliminating the ‘one size fits all’ approach currently used by the Medicare program.

Sponsors: Representative Steve Cohen

                   William L. Stotts

Committee: Health and Finance, and Commerce

A Bill

To ensure that the ongoing needs of Therapy and Rehabilitation Medicare Part A recipients are met for those whose needs truly extend beyond 100 day benefit period and to  provide for categorization of such needs there by eliminating the ‘one size fits all’ approach currently used by the Medicare program.

Section 1 – Short Title

The Act may be cited as the ‘Medicare Benefit Period Reform Act’.

Section 2 – Purpose

Be It Enacted by the 113th Congress 2nd Session

Whereas Medicare, as it currently stands, categorizes every individual regardless of his/her medical condition into one category for purposes of the one hundred (100) day benefit periods, and

Whereas for Nursing home care and rehabilitation purposes, persons needing a knee or hip replacements get up to one hundred days of therapy and nursing home care if needed, and

Whereas for those persons mentioned above, one hundred days may be sufficient, and

Whereas persons suffering from catastrophic events such as a devastating stroke, are also entitled to up to but not more than one hundred days of therapy and nursing home care for the original event, and

Whereas one hundred days is not enough to make any kind of decent recovery in many situations including devastating catastrophic strokes, and

Whereas many of these persons have worked all of their lives and may have paid into the Medicare and Medicaid programs since their inception in 1965, and

Whereas these persons are entitled to benefits for which they have paid or have been paying even though the need may exceed the one hundred day benefit period, and

Whereas many persons in need of extended benefit periods have paid into the program since its inception in 1965 to subsides benefits received by persons whom may have never paid into the Medicare / Medicaid program and whom have also been recipients of other non-entitlement benefits such as welfare and AFDC,

This one hundred and thirteenth Congress in the interest of humane, fair and equitable treatment should vote and pass this Bill and it should be signed and enacted by the President of the United States, Barack Obama.

Section 3 - Enactment

This Bill, if enacted will create categories based on the degree of need and scale the benefit period to that need. For example, knee or hip surgery or replacement may necessitate one hundred days or less of rehabilitation therapy. A devastating stroke on the other hand may require one or more years. In the example of a devastating stroke, a patient may just be beginning to show progress when Medicare as it is currently structured literally pulls the rug out from under the feet of those in need. 

This Bill, if enacted will take effect 91 days after passage and will be funded in such a way as is consistent with current Medicare funding.

 

William L. Stotts

williamstotts@bellsouth.net

 

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