A family member with multiple health problems is under "observation" status at a hospital, and due to be released soon. This person is not able to take care of himself at home. The Medicare Advantage plan has denied coverage for further care, and local facilities with openings have declined admittance under self-pay. If anyone has successfully appealed a MA decision, please advise anything that was helpful.
Observation status doesn't qualify for any rehab or after care. It is just ridiculous that hospitals don't admit patients but keep them for days under observation knowing full well that the person will not get after care but will have deteriorated from laying in bed for days.
Get the hospital to change the status. That is the 1st step.
Is it time for long term care? That will never be approved by insurance, they don't cover that care.
I know you've been told that by people that should know, but they don't. There is no "improvement standard" for medicare coverage. Quite the opposite in fact. I've posted links to all the supporting documents so many times that I can't be bothered to do it again right now. So I'll just post this one. Directly from medicare.
"Such a maintenance program to maintain the patient's current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective performance of the program. "
https://www.cms.gov/Center/Special-Topic/Jimmo-Center
That is the real requirement. As long as the care will "slow further deterioration" then it's covered by medicare. No improvement necessary.