Hospice Care and Medicare: LTCI Insider

This is a must-read article if you are on Medicare, or a loved one is on Medicare.

Here is something that happened to me earlier this year…

I am sitting by my mother's bedside in her hospital room. I'm holding her hand, but she doesn't even know I'm here.

My brother and I have just decided to do hospice care for Mom.

Two weeks before, she was doing great — I even hosted her 99th birthday party. Then I received the call no child wants to get: She had fallen, suffered a stroke and two brain bleeds, and was on her way to the hospital by ambulance.

Several days later, when there was no improvement in her condition, we reluctantly selected hospice care.

Chris, my mother's new hospice nurse, is now suggesting that we move her to their free-standing hospice facility. It's a nicer environment for her last days, plus it's closer to my house. It seems like a logical solution.

I then ask Chris, "Will Medicare pay for the hospice facility?" He assures me that it will. Several minutes later, I repeat the question, and he again says yes. (Thank goodness, I had witnesses both times when I asked.)

The next day, Mom is moved by ambulance to the hospice facility. When my husband and I arrive, Paul, the hospice nurse greets us at my mother's bedside.

Everything is proceeding smoothly… until we have this conversation about payment.

Paul: Margie, I need you to sign this paper. It explains that Medicare will cover her for two days and then it is private pay.

Margie: That is not what I was told in the hospital. I was told that Medicare will pay for everything.

Paul: You obviously heard wrong. You were upset and didn't understand.

Margie: I am a national expert in what Medicare covers in the area of long-term care. I definitely know what I heard. Please explain this.

Paul then shows me the paper he wants me to sign. Here are the two paragraphs he is referring to:

General Inpatient Care (GIP): Under this level of care the hospice house provides short term care for acute symptom management much like a hospital setting. An appropriate plan of care including discharge/transfer will be developed on admission. Physician oversight and direct care provided by hospice nurse staff address symptoms such as acute pain, nausea, unresolved vomiting, anxiety and restlessness that cannot be managed in a home type of setting. Once symptoms are managed the patient will be changed to routine level of care for transfer planning.

Routine Care: When a hospice patient's disease is progressing without the need for acute symptom management, they are considered routine care. If a patient is admitted to hospice house under routine care, transfer planning will begin on admission to the hospice house. Under this level of care the Medicare hospice benefit does not pay for room and board. Room and board is the responsibility of the patient and/or family and is based on ASSETS then INCOME. The hospice house is not a long-term care facility; therefore, the social worker will assist with placement in an AFL/LTC facility or home setting of patient/family choice?

Margie: How much will this care cost each day?

Paul: It depends on her assets and income. That's all the information I can give you.

At that point, my patience runs out.

I then mention that I write a column for a national publication that reaches thousands of readers and will do an article about this. Paul cannot leave the room fast enough.

One Hour Later…

Paul returns to explain that a conference call has been arranged with Sara, the head administrator at the facility.

During the call, I repeat the information I had shared with Paul. Finally, reluctantly, I again mention my national column. There is a long silence, and then Sara tells me not to worry — she will work with the billing department and we will not be billed for the additional days.

The hospice facility does adjust the billing. A month later, I receive a Medicare statement showing almost $1,000 a day has been paid to the facility for mom's care.

I have won the battle, but…

I was totally shocked by what almost happened with billing, in addition to dealing with the trauma of my mother's quickly approaching death.

What worries me is that, if I encountered this situation — and I do understand Medicare — what about others who hear that Medicare will pay for hospice, and then receive a bill for thousands of dollars?

I don't want this to happen to you or your loved ones.

In retrospect, I think this may have occurred because the hospital hospice nurse was relatively new and maybe didn't understand the difference between the two payment structures.

And — this is important — most long-term care (LTC) policies will pay for hospice care.

Most of the newer policies contain a specific hospice benefit. And many others include an alternate plan of care provision which should cover the hospice cost up to the daily benefit amount. In the trauma of this situation, it didn't even occur to me think about my mother's long-term care insurance (LTCI) policy.

This situation occurred in Florida. What about in other states? To get that information, I consulted with Dr. Katy Votava, president of GOODCARE.com and a national expert on Medicare.

Here is her explanation: "Hospice" is a term in general conversation that refers to providing care near the end-of-life. That said, the meaning of hospice in the Medicare program is precise and narrow compared to how most people think about hospice. That phenomenon contributes to the dissonance between what we expect of hospice and what Medicare covers.

The Medicare hospice benefit covers a wide variety of services in various settings, including people's homes, hospitals, long-term care facilities, and free-standing hospice homes. Recipients need to meet Medicare hospice program eligibility criteria for services to be paid for by Medicare. As is often the case with Medicare, these criteria are unfamiliar and confusing to individuals and their families.

In this case, Margie received one interpretation of what Medicare would cover for her mother before transferring her to the hospice facility, and then a very different explanation upon admission. In the process, the family did receive a Medicare hospice document that mentioned "routine" care. Yet, nothing about transferring your mother to hospice is "routine"!

The Center for Medicare and Medicaid Services (CMS), which oversees Medicare, is aware of this type of regrettable situation. There's a new Medicare hospice rule, effective in October 2020, that says Medicare hospices are required to include an "addendum" to the hospice election statement outlining non-covered services, supplies, and medicines. The objective of this procedural change is to enhance financial coverage transparency upon admission and hold hospices accountable.

Also, family caregivers need to know about the right to advocacy and the appeal of Medicare determinations. CMS sponsors the Beneficiary and Family Centered Care-Quality Improvement Organizations (BFCC-QIOs) help Medicare beneficiaries get high-quality health care. BECC-QIOs can assist with complaints and quality of care reviews, appeal a health care provider's decisions, and offer immediate advocacy to address complaints quickly.

More information about Medicare's hospice coverage is available on the Medicare hospice care website.

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Margie Barrie, an agent with ACSIA, has been writing the LTC Insider column since 2000.