Hospice is primarily paid for by Medicare or Medicaid sometimes a combination of both, for reasons that are so convoluted it would make your head spin, and Private Insurance. The requirements for Medicare and Medicaid are somewhat consistent and each Private Insurance company is different because, you know, free market. Whatever.

Now I you’re like, ok Martha but like why does this matter? Having a concept of general Medicare regulations in regards to Hospice is going to benefit you, in major way, in understanding what care is going to be provided and where you are going to have to fill in the gaps for your family member. 

Remember when I briefly touched on IPU’s (In Patient Units)? We’re going to come back to that in this post.

When your person comes onto hospice. They get a diagnosis, determined by the nurse and the Hospice MD. It will not always be the diagnosis that you person was given by the PCP or Hospital doctor. This is because there are certain diagnosis’s that are not accepted by Medicare. It could also be that the primary disease as not progressed to the point of eligibility of care, but due to co morbids and other factors your person is appropriate. Example, maybe your person has Alzheimers but they can still talk, recognize their grandkids, would not really be eligible for Alzhiemers according to Medicare.

When your person gets this Diagnosis (DX), Medicare looks at it, and then pays a flat rate to the hospice of what they think it costs to take care of that person. Medicare also pays for certain things and expects you (the caregiver) to pay for the rest. Medicare pays for Nurses Visits, Nurses Aide visits, Social Worker Visits and Phone Calls, Prescription drugs related to (DX), Half of a Patient’s supplies, DME (In Home Hospital bed, oxygen, walkers, wheelchairs, etc.). Medicare also pays for caregiver respite. Now respite is one of those tricky things cause there are a lot of caveats, but it kind of operates in a grey area. Respite as defined by Medicare is five days. And it is to be used sparingly.

Now I know what you are thinking, this is nice and everything, but what does this have to do with me? It’s good to know so that you can understand why certain choices are being made by the hospice in regards to your person’s care. And so you can know how to make arrangements in regards to your person’s care. 

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Example asking for respite once every month would be a no no. That is something that could get the hospice flagged by medicare. This is where the IPU comes back into the picture. When you ask for respite your loved one goes to the IPU. That is the physical place that people commonly associate with hospice. IPU’s serve other purposes, if the patient is having a crisis, patients can be placed there until the crisis is resolved. A crisis can be uncontrollable agitation, unmanageable pain, caregiver emotional breakdown etc. But there has to be a reason. Now there are IPU’s and you can take your loved to be in to die in, but you have to pay. The hospice can’t bill medicare.

Something that is very frequent here that happens is that, a hospice will talk up the IPU and families will get the impression that their person can just stay there. The hospice will admit the patient and then take them to the IPU, and while they are there will scramble around looking for placement for the patient and then when the five days are up, will then move the patient into the placement they found, usually a nursing home cause Medicaid will pay and kick in, or tell the family that they have to take their loved one home or tell the family they have to pay. That’s why I always say be wary of hospices trying to sell you that particular story. 

In reality there are a lot of things that hospices are either prohibited from doing, will not do due to medicare payments, or will fudge for the sake of good patient care.

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Example. Medicare says that a nurse only has to make in person visits once every 14 days. Due to this a lot of profit driven hospices will strictly adhere to this. And other hospices who care about patients will fudge this and see patients twice or three times a week dependent on the condition of the patient.

Private Insurance is a wild card, and Hospices take it, but are usually wary of it cause Private Insurance has a lot of hoops they have to jump through if the hospice is not in network. The only thing is that there are considerably less rules, with private insurance in terms of compliance.

Now what if you don’t have insurance and your too young to start recieveing medicare?

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Usually, the person will still be admitted and the hospice social worker will get the medicaid application started.

What if your person, has no insurance and then is undocumented therefore no medicaid and no medicare?

Your best, is find a big large corporate hospice and ask for your person to be on service. Hospices take those kind of cases. A smaller Hospice is going to have a hard time absorbing the cost, but a larger hospice is going to have the resources to care for patients without the ability to pay.

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Next time, We’re going to get into Medicaid. Assisted living facilities and Nursing Homes.