June 11, 2025

2 Midnights

This week’s posts have been about overload and that’s such a significant part of the Sandwich generation, but today I want to highlight a stand out experience with the hospital system this week that I truly hope can help others better advocate for their loved ones.

We got to work with the Medicare 2 midnights rule for the first time this week with Mom. We are learning to find our way with very little guidance through a system that seems to be the furthest from user friendly. Let me be your guide as you prepare to support your loved ones in the future!

Long story short this time it was a large blockage much further down than recently and I just don’t know how that happened because she’s been on a liquid diet. The surgeons said earlier yesterday that they could admit her to an observation area of the ED and get her bowel regimen figured out, but that they are still not going to operate at this time and the plan remains the same (go home on liquid diet and await elective surgery probably in August).

BUT I didn’t realize (and THANK GOODNESS my husband understands this insurance stuff better than I do and was paying attention), that she was STILL in the ED last evening and it had only been ONE MIDNIGHT! I talked to a Utlization Review expert who works for the big hospital and she confirmed (which my husband suspected) that if we picked her up before midnight last night, which we did, it’s before the “two midnights rule” so then she DOESN’T lose her 3 weeks at home!!!!!!!

Let me explain- Mom’s Medicare plan has a certain number of inpatient stay days. These days covered her many inpatient hospitalizations and also were used anytime she was in an intensive rehab instead of going directly home from the hospital with home health or instead of going to a skilled nursing facility for rehab (this is billed out of a different “bucket” of Medicare funds). We knew very little and along the way one of the small hospital’s staff members (I believe a social worker, but I have no idea who it was) told me that inpatient days were unlimited so I fought hard for Mom to stay admitted through an infection and unexplained pain and several stretches of time when she was unable to eat. If I had known we were burning through limited days I would have handled things differently. She certainly should have been in the hospital during those times, but it’s clear that we cannot always get and maintain the care that is needed for as long as it is needed. There are definitely limits. I also was under the impression that the intensive rehabs were paid from the same bucket of as the skilled nursing facilities. I also spent an hour and 20 minutes one day not long ago on the phone directly with Medicare during this journey and was given completely wrong information after a long conversation where I asked very specific questions, sharing my knowledge and Literally having someone who works for Medicare stating the complete wrong thing about my Mom’s plan and which parts of Medicare pay for each level of care. Because she used so many inpatient days or days that count as inpatient (part of this was after a surgeon nicked her and she had to go on a wound vac, prolonging her inpatient stay days) she is now well into what are her 60 lifetime days for inpatient and once those are gone, they are gone. The other days will re-up every time she is able to be home for 60 days straight. Being in a skilled nursing center for rehab, while out of the hospital does not count as being home. So even though she had no readmits for more than 20 day while in her second skilled nursing facility for rehab, none of those out of hospital days counted toward the 60 at-home days she needs to put together for her inpatient days to re-up.

So yesterday I figured this out at like 4:20 PM when my husband re-explained it (we’ve never been able to discharge ahead of the two midnights while still in an ED before) so I started frantically calling the staff at the big hospital, and after talking with like 5 people I got my message across and I spoke to the surgical team and they said if she ate her liquid dinner without any problems they would check on her after dinner. It worked out and my husband and I were able to go get her. She was still on Medicare Part B so we are still on 3 weeks at home and counting as we try to get to 60 days straight at home for Medicare A benefits to re-up. Shout out to my mom’s AMAZING first shift nurse yesterday in the ED who sprung into action when I called and got us Everyone’s attention that we needed to get her out and home in time. Now we wait and hope again and it looks like home health can restart pretty seamlessly!