Hospice care not covered under Medicare Optum

[51togo]

My mom is 94 and fell two weeks ago. She lives independently after my dad passed 5 years ago at home with heart issues. She got early stage of dementia but rather good health. My sister is her main caretaker with a recent POA. My brother and I would stopped by several times a week to help with the house and cleaning etc. After a week from the hospital with internal bleeding controlled and fractured pelvic but not recommended surgery instead weight bearing PT then released to nursing home. Yesterday her situation deteriorated quickly to heart rate of 140 with Afib, cannot speak, and not eating. Attending doctor advise us either return to the hospital or hospice care. After a short discussion among us, it is clear that hospice is the best path forward. Then the nursing home director advised us that Optum will not pay for hospice as it is considered LTC. The current facility is $11k a month and he gave us agents to look for other hospice facility in the range of $4k/ mo. Going back to the house is not an option at this time. Also finding out that mom’s bank account is at $90k so she would not qualify for Medical, we are in So Cal. Leaving voicemails to several recommended agents. I’m finding out a whole new world of hospice coverage out there, mostly in a private home and seems little accountability. So with my mom at 94 I realized it’s inevitable but still feeling overwhelming and any suggestions appreciated!

 

[Teacher Terry]

I would use her 90k to pay for a nice facility. It sounds like she won’t live long enough to run out of money.

 

[cathy63]

I'm sorry you're going through this. I do think you should apply for Medi-Cal for her, even if you think she won't qualify. The law changed at the beginning of this year so that CA no longer looks at assets, only income. Let the state be the one to make the decision on whether or not she qualifies.

 

[wolf]

I would use her 90k to pay for a nice facility. It sounds like she won’t live long enough to run out of money.

Agree. Use the $90K to pay for the 11K per month, if the facility is nice. Not eating. Time is very short.
Been there.

 

[braumeister]

Agree. Use the $90K to pay for the 11K per month, if the facility is nice. Not eating. Time is very short.
Been there.

Yes, that's what I would do (and have done).

 

[rodi]

I agree that using her money to pay for a nice facility, while concurrently applying for Medi-Cal.

When my sister's MIL needed hospice they had to change the facility (she had been in assisted living) to a higher level of care (but still assisted living) AND bring in extra nursing. There were very few hospice specific facilities, at the time, in San Diego.

 

[51togo]

Thanks for quick replies! Feeling better to not move her although my sister thinks necessary to preserve her funds. Not really a nice facility but one of those assigned by Optum, I’ve visited another insuring home for about the same $11k but much better conditions and faculty. However, as you guys suggested time is short so I agree better option to leave her in current state without more disturbances to maintain comfort. So I’ll deal with the siblings dynamics later also may be always helpful for us to apply for Medical under same nursing home address. Thank you!

 

[braumeister]

Thanks for quick replies! Feeling better to not move her although my sister thinks necessary to preserve her funds.

Preserve her funds for what? I suspect your sister just hasn't thought this out.
My guess is that your mom may be doing what quite a lot of folks at that age and health condition do -- essentially hurrying the process along by deliberately not eating. Malnutrition will hasten the end with very little fuss.
I've seen this in my own family.

 

[MC Rider]

I'm sorry you're going through this. I do think you should apply for Medi-Cal for her, even if you think she won't qualify. The law changed at the beginning of this year so that CA no longer looks at assets, only income. Let the state be the one to make the decision on whether or not she qualifies.

Yes on this. Although they may not decide fast enough.

 

[UpQuark]

I would use her 90k to pay for a nice facility. It sounds like she won’t live long enough to run out of money.

+1

My mom and I worried a lot about the money when my father went into care, but he died after only three days. They recognized that he was dying and contacted my mom. She didn't get there in time, but someone at the facility stayed with him and held his hand.
So, I think use her money to give her the easiest experience.

 

[athena53]

I mentioned this to my friend who works for a government contractor answering calls from Medicare beneficiaries. Is your mother in an Advantage Plan? He says that the type of hospice care she requires should be covered by 100% traditional Medicare. Open enrollment is over but he says you can switch her back by first enrolling her in a prescription drug plan. No, I don't understand that, either, but he says the hospice social worker may be able to help. It sounds like she doesn't have a lot of time left but it may be an option if she lingers for awhile. Please keep us posted.

 

[51togo]

My mom is not on a Medicare Advantage Plan, but Medicare under HMO Optum part of United Health. So my understanding is hospice services and medicines etc is covered. But not room and board, the current vendors suggested hospice locally are in private houses (for profit ) taking care of 4-6 patients at the range of $4k monthly.

 

[Pluperfect]

Open enrollment is over but he says you can switch her back by first enrolling her in a prescription drug plan.

Original Medicare is who pays for hospice care, regardless of whether a person has an Advantage plan or is on Original Medicare. A person with an Advantage plan can begin Medicare's hospice benefit and still remain on the Advantage plan if he continues to pay the premiums; that way he can continue to receive the other benefits offered by the Advantage plan (dental, vision, OTC benefits, for example).

As far as I know, there is no difference in the hospice benefit for people on Advantage and people on Original Medicare, but it's important to understand that the hospice benefit applies only to care related to the terminal illness, and even that doesn't extend to care to treat the terminal illness, because you give that up when you enter hospice care. But if you have other conditions that are unrelated to your terminal illness that you want treatment for, the hospice benefit doesn't cover any of that; basically, and very generally, hospice care is carved out of the regular Medicare scheme and gets covered differently from the non-terminal conditions.

So my understanding is hospice services and medicines etc is covered. But not room and board,

Right.

Medicare doesn't cover room and board if you get hospice care in your home or if you live in a nursing home or a hospice inpatient facility. If the hospice team determines that you need short-term inpatient or respite care services that they arrange, Medicare will cover your stay in the facility.

medicare.gov/coverage/hospice-care

I hadn't heard of private homes that care for hospice patients, but I suppose they have a place, for people who don't have people at home who can provide care for them (whether family or paid workers). I'm assuming these private homes are licensed by somebody, right? (Of course nursing homes are licensed, too, and we know the variability among them.)

I worked in administration at a nonprofit hospice a couple of decades ago. Even back then there were some issues with bad actors, but since then it's become the wild west. The New Yorker did a long (of course it's long--it's The New Yorker) article about hospice fraud that I found distressing, but informative.

newyorker.com/magazine/2022/12/05/how-hospice-became-a-for-profit-hustle

And one more thing--as far as I know you don't necessarily have to choose between hospice care and being in a hospital ("Attending doctor advise us either return to the hospital or hospice care.") Hospices provide hospice care in hospitals, but the patient can't be receiving treatment for a terminal illness (but could be in the hospital for other reasons). It probably doesn't apply to your mother's situation, but hospital and hospice are not always an either-or.

 

[RetiredHappy]

I think OP is referring to the 6-8 room board and care residential home. They are licensed but they are not specialized for hospice but they may take a hospice patient if they are desperate to fill the bed. They don't have nursing staff in those places. I would not put someone on hospice into those homes. Granted, many do pass away in those residential homes, as part of the continuing care.

 

[51togo]

I think OP is referring to the 6-8 room board and care residential home. They are licensed but they are not specialized for hospice but they may take a hospice patient if they are desperate to fill the bed. They don't have nursing staff in those places. I would not put someone on hospice into those homes. Granted, many do pass away in those residential homes, as part of the continuing care.

Correct and after visited 2 residential home, I’m not convinced she’ll get the best care there. It’s mom’s $90k, it should be used now for best care and in this case stay where she is. Learning a lot, I’m thankful to have purchased LTC when I was 53 just 2 years before my retirement now 68, when the annual premium arrives I often thought it was too much, not anymore. Thank you all!

 

[SecondCor521]

My mom is not on a Medicare Advantage Plan, but Medicare under HMO Optum part of United Health. So my understanding is hospice services and medicines etc is covered. But not room and board, the current vendors suggested hospice locally are in private houses (for profit ) taking care of 4-6 patients at the range of $4k monthly.

I think you have the right understanding here.

My Dad has mid- to late-stage dementia, is 88, and lives in a memory care facility. He pays $XK per month to the memory care facility, which covers room / board / activities, help with ADLs, and staff nurses. That's his living situation.

Separately, he has a FNP who visits him and is his primary care doctor providing the main POC for things like dementia, depression, UTIs, foot care, etc. She will recommend hospice when that time comes. Hospice covers medical attention, counseling, and some stuff like shower help and incontinence supplies.

He's on a Blue Cross Medicare Advantage plan, and everyone has led me to believe hospice is 100% covered. I don't think the insurer matters.

I'm sorry about your Mom and hope you can spend some good time together.

 

[EastWest Gal]

Then the nursing home director advised us that Optum will not pay for hospice as it is considered LTC.

There seems to be a problem with definitions, and the nursing home director seems to be confusing the issue. She may be trying to state that being in a skilled nursing facility is what is not being covered.

Hospice is palliative care for someone who is not expected to live more than six months. It is a type of care, not a facility, and it definitely is not LTC. Medicare will cover up to 100 days in a skilled nursing facility, the first 20 days 100%, then with a copayment up to 100 days. This is true for regular Medicare, but Medicare Advantage plans, one may be charged a copayment for the first 20 days. This 100 day rule is a lifetime benefit-you get only 100 days, period.

One can be in a skilled nursing facility, a hospital, assisted living, or at home, under hospice care. Hospice care is covered under all Medicare plans, I believe.

I also think that it is likely your mom has a Medicare Advantage plan under UHC, since every website I looked at describes Optum as a health care company, not an insurance plan, and that Optum contracts with various Medicare Advantage plans. It is also a subsidiary of UHC Group. If your mom has an HMO, that is Medicare Advantage in a nutshell.

Just my two cents. My dad had hospice care while at assisted living, and it was me hiring private caregivers in the assisted living facility that kept him out of a nursing home. I think you may want to reach out to Medicare.gov and Optum directly to get some clearer answers regarding your mom's care and skilled nursing care coverage, rather than just the nursing home administrator.

 

[MBSC]

I mentioned this to my friend who works for a government contractor answering calls from Medicare beneficiaries. Is your mother in an Advantage Plan? He says that the type of hospice care she requires should be covered by 100% traditional Medicare. Open enrollment is over but he says you can switch her back by first enrolling her in a prescription drug plan.

Hospice is covered by traditional Medicare even when the person has an Advantage plan. They don't have to switch.

If you’re in a Medicare Advantage Plan:

* Your plan must help you locate a Medicare-approved hospice provider in your area.

* Original Medicare will cover everything you need related to your terminal illness once your hospice benefit starts, even if you stay in your plan.

* Your plan can still cover services that aren't part of your terminal illness and related conditions.

Hospice care

Have terminal illness or know someone who does? Get hospice care coverage. Choose between in home, inpatient facility care. Learn more at Medicare.

www.medicare.gov

Original Medicare will cover care for your terminal illness and related conditions. Once you start getting hospice care, your hospice benefit should cover everything you need related to your terminal illness, even if you remain in a Medicare Advantage Plan.

https://www.medicare.gov/publications/11361-medicare-hospice-getting-started.pdf

 

[rodi]

My step mom was at an assisted living place for about 10 years. She had a significant pain develop and went to the hospital. They did scans and determined she had a large mass, but the only way to know what it was was surgery, which she declined. She was a PhD nurse and knew the risks of surgery as well as odds it was likely terminal... And she was 94. She opted for hospice... But her old assisted living apartment couldn't provide the care she needed. Working with the Kaiser social worker she found a private room in a board and care facility. (A neighborhood house that had round the clock nursing.). Hospice nurses came 2-3 times a week. Occupational and music therapists also came. Visitors were welcome. She spent 9 months there till she passed.

It was much cheaper than a hospice nursing home. About $8k/month

 

[Pluperfect]

Hospice nurses came 2-3 times a week.

That's something a lot of people don't understand about how hospice works.

 

[Koolau]

That's something a lot of people don't understand about how hospice works.

Hospice nurses came 2-3 times a week.

I have always wondered how Hospice handles "crises" (such as sudden breathing issues, changes in pain levels, infections, etc.) Preventing the "misery" of dying is what I thought Hospice was all about. I would think that might require more than a few visits per week in many cases, but I have no experience with Hospice.

Can anyone educate me (us?) Thanks.

 

[athena53]

Preventing the "misery" of dying is what I thought Hospice was all about. I would think that might require more than a few visits per week in many cases, but I have no experience with Hospice.

Can anyone educate me (us?) Thanks.

DH was in hospice care at home his last months. I made a frantic call to them two days before he died when he was in "terminal agitation"- I knew nothing about it. All I saw was that he kept trying to get out of bed, I couldn't reason with him (he was frail and would have fallen) and I had a meltdown of my own. They were calm, they directed me to the box of meds that had been delivered early on and told me to give him a dose of morphine. They came over soon after, and also called his doc to get authorization for higher doses of morphine. So, apparently they're on call for sudden changes. The other visits were more routine.

The next day he wanted to go for a drive. It was one of my fondest memories- I could barely get him into a wheel chair, down the two front steps and into the car, reversing it all on the trip home, but we drove around a nearby lake, we had a good talk and stopped to get him a banana milkshake at DQ. In retrospect, it was another form of terminal agitation- wanting to see the world outside our bedroom just one more time.

 

[SecondCor521]

I have always wondered how Hospice handles "crises" (such as sudden breathing issues, changes in pain levels, infections, etc.) Preventing the "misery" of dying is what I thought Hospice was all about. I would think that might require more than a few visits per week in many cases, but I have no experience with Hospice.

Can anyone educate me (us?) Thanks.

When my Mom was on hospice, there were regular weekly visits from the nurses, but if she ever had any emergencies, then there was a way to get a hospice nurse to come "right away" - definitely same day, and within an hour or so was an option. You just call the hospice dispatch folks. Since my Mom was in a larger retirement community, the hospice nurses were often there anyway visiting another patient, so they could make an impromptu visit to my Mom if needed (or send out a spare nurse from central). I think this happened a few times with my Mom in the ~9 months she was on hospice.

If it's more critical than that, then hospice patients still could call the paramedics. My Mom never did, but we knew it was an option.

My understanding is it sort of depends on the context of the crisis. If it's related to why the person is on hospice, then the idea is to make them comfortable and have a good quality of life in their last few months and days, so typically a paramedic call in this scenario would not be followed by an ambulance ride to the ER.

If the crisis is unrelated, like if someone is dying from cancer but choking on a chicken bone or cut a major artery while slicing a bagel, then the paramedics would do the Heimlich or stop the bleeding, and follow up care for that could be done.

It is also my understanding that a person on hospice can elect at any time to go off (and then back on, and then off, ...) hospice. Most do not, but it's an option.

Finally, my Mom's hospice provider was pretty liberal with the oxygen and the morphine. She had plenty on hand to avoid any pain.

Oh, and my Dad may go on hospice sometime in the next while. He's already in a memory care situation, so there are nursing techs onsite 24/7 and nurses in the building most of the time, so they can also provide first aid and get in touch with paramedics and/or family members as needed. There were also nurses and caregivers around when he was in assisted living. I would think most people on hospice are already in either assisted living, memory care, a hospital, or some other form of SNF. The caregivers and nurses can (and do) bridge the gap between first aid / family / paramedics / hospice / hospital as needed.

 

[RetiredHappy]

I have always wondered how Hospice handles "crises" (such as sudden breathing issues, changes in pain levels, infections, etc.) Preventing the "misery" of dying is what I thought Hospice was all about. I would think that might require more than a few visits per week in many cases, but I have no experience with Hospice.

Can anyone educate me (us?) Thanks.

During the last couple of days, hospice nurse can spend many hours a day there.

 

[rodi]

A friend passed away Christmas Eve after a few weeks on hospice. Most of the day to day care fell on his wife.. But like my step mom she has assistance from both hospice nurses and PT types a few times a week. His last few days the visits were more frequent. He had started having seizures and hospice put him on anti seizure meds as well as pain meds.