Question about medicaid and home health vs hospice

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notBrad

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04/2015
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So we only have one company in the area that does home health and hospice. Right now I am getting pt twice a week along with an aid that helps Vicky shower and shave me.

Twice now they have had a rep come by and " advise" us. He is really pushing us to switch to hospice and go on medicaid even though we would have to divulge ourselves of a fair amount of assets to qualify.

Other issues we have are losing pt as well as the probable loss of coverage for the riluzole and nuedexta. Also, they keep bringing up how much additional help we could get thus freeing Vicky up to get a job.

Problems we have with the recommendations along with the aforementioned loss of drug coverage and having to shed assets are my no longer receiving pt and having someone " around" all the time (why should Vicky spend time away from me at a job just so someone else can pull a check doing things she does).

Other big issue is the medicaid liens that get placed on your property.

In short we feel we're being " up sold" so they can maximize billing when I don't really need hospice care yet and we would have to put ourselves in a precarious financial situation to qualify for medicaid.

Also I have a great plan F that only cost 140 per month.

Thoughts anyone?
 
Sorry my friend, I live in Canada not much advice I can give you on that stuff.
 
You should check out http://www.medicareadvocacy.org/wp-content/uploads/2016/07/ALS-MAP-Webinar-2.pdf relating to Medicare home health benefit for ALS patients. Basically, it says there is a federal statute that provides for up to 35 hours per week of care, although each daily visit must be less than 8 hours. (Not enough for many PALS, IMHO, but certainly more than you are getting right now.) Here is the text from the key slide:

[mod note: benefit is allowed under Act, but not mandatory in any particular case, since expectation of improvement is still official policy except for small pilots and custodial care remains outside policy]

How Much and How Long
Can Care Be Covered?
 Up to 28 to 35 hours per week combined of nursing and home health aide services (Medicare Act: 42 USC 1395x(m))
• In practice, difficult to find an agency to provide
 And PT, ST, OT as medically necessary and reasonable
• Note: OT can qualify as the skilled service to continue coverage, but not to trigger it
 No duration of time limit. Coverage is available so long as skilled care required. Medicare Benefit Policy Manual, Chap. 7, §40.1.1

Each state has its own Medicaid program, so you need some local advice about that. It's quite possible that Medicaid will provide better home health benefits than Medicare.

Medicare won't provide a hospice benefit without a 6-month life expectancy. If that is your prognosis, the Medicare final rule does provide for coverage of all home health services and equipment that are medically necessary to palliate all symptoms related to ALS, including the services of aides (for ADLs) and practical nurses (for administering meds, tube feedings, operating respiratory equipment, etc.). Finding a hospice that will actually provide all necessary services, however, can be a real challenge. (Medicare does not consider ALS in its methodology for setting its system for reimbursing hospices, resulting in a system that puts a big financial burden on a hospice that provides all the care a PALS needs.)

If you elect to go the Medicaid route, you should consider finding a good local disability rights lawyer and ask them how the "integration mandate" of the ADA can be used to ensure that Medicaid provides you with all of home care necessary to keep you out of a nursing home (and tell them to check out cases like Pablo Carranza v. State of California, where a Medicaid muscular dystrophy patient (very similar to ALS) successfully sued to keep his 24-hour nursing care). For reasons I won't bore you with here, disabled Medicaid patients have an easier time getting legal help than disabled Medicare patients.
 
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I think I veered off track in my previous response.

In general, hospice covers more than “home health” for PALS, and Medicaid often provides more than Medicare for disabled persons. Medicare won’t provide a hospice benefit without a 6-month life expectancy, so you should ask your neurologist about that if you haven’t already. If you have a longer life expectancy, the question of whether to elect hospice may be moot.

I don’t understand why you would lose Neudexta coverage in hospice. My wife’s hospice covers Neudexta. If it palliates your ALS symptoms, it is supposed to be covered by hospice. I don’t know if riluzole has a palliative purpose, but this is another thing you could ask your neuro.

As for who provides the care, I believe family caregivers are almost always better than hired care workers. As your condition progresses, it may become a lot harder for Vicky to do everything you need. Again, you should talk to your neuro about your rate of progression and what to expect in 6 months, 12 months, etc. and make sure you plan ahead. I suggest avoiding a situation where you find that Vicky is no longer able to do it all and don’t have a plan in place for that eventuality.

As for “upselling,” have you asked your agency if they stand to make more money if you go on Medicaid? You need to be able to trust them, so hopefully they will be open and honest with you about any financial interest they have in your care plan.
 
Based on the information you provide, this is not something I would do. It does sound like an upsell, which benefits the provider rather than for you.

Be aware that divesting assets to qualify for Medicaid can be problematic. It has the potential to be disallowed. If it is found to be disallowed, there is the potential for clawbacks. I would not consider doing this without very sound and thorough legal advice from a very good attorney who specializes in this field.

Steve
 
Personally, we would not even consider impoverishing ourselves to do Medicaid even if that were possible for us. I know the rules on all of that are different for Seniors. I agree with the person who said speak to an attorney.
 
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Nice to see sumpin from you Brad. Sorry it is an issue that brings you back.

Type F Medicare is the best plan you could have from what I have read and heard.

As far as Medicaid goes you will have problems with them because of your assets. They think you are not deserving of benefits if you own anything at all.

An example of this is with my mothers treatment by Medicaid. They found out she had purchased (10 years back) a burial policy, and ended her benefits. I had to get advice from an attorney on this. He suggested that I buy an upgrade plan and cash moms in and put in my name. That worked, but just sayin they are BASTIDS. Her policy was only worth 2 grand, yet they called it an asset.

If you wanna put that motorhome in my name it wouldn't break my heart.
 
Unfortunately, each state has specific laws as relates to financial assets, income, etc. and there are also Federal laws. I would definitely consult an attorney and I would make sure she/he has a specialty in estate planning AND elder care.

Sometimes it's possible to establish trusts for your own benefit (the disabled party) or your spouse's benefit, thus protecting those assets.

The ONLY advice you should take is from an attorney.
 
Regular Medicare or Medicaid should continue to pay for riluzole if/as the hospice agency doesn't, as they would any other rx you were taking, as it's a maintenance drug, not a fix-it drug. If there were any fix-it drugs for ALS, they would not be covered in hospice either way, i.e. cancer pts have to stop chemo.

Nuedexta should be treated similarly but ask the hospice billing person as it's fairly new and unusual in this context. Your doc may need to document its palliation properties.

Not familiar w/ Oregon, but in most states HH income is a consideration so if Vicky started a new job, that income would call your eligibility into question. This firm is looking at you as a cash cow. They get a per-month allowance on hospice and they don't have to spend it on you (a flaw in all hospice care, BTW).

I certainly would speak with an attorney who doesn't do hundreds of these a year (i.e. is objective, as might be a local not-for-profit) before pulling the trigger on something like this. But from what you describe, I'm not hearing anything positive as a reason. And the Medicaid mill limits your care choices, just as hospice does.

As for Vicky suddenly finding herself unable to care for you for a long period of time, that's unlikely (I'm presuming you have enough for her to have some help). Most PALS do not opt for invasive ventilation but even then, unless you are bedbound and you don't sound like a guy who wants to be vented and bedbound, the nightmare scenario Dave describes is unlikely to occur. The reality that most of us live through is that a PALS at some point wants to or has to let go.

I am not minimizing what Vicky is dealing and will deal with -- how could I? But Medicaid in your situation doesn't seem like an answer.

Best,
Laurie
 
Thanks for the very informative responses everyone. They definitely helped us out a lot. At this stage hospice is way too premature, I still have some function in my arms and good strength in my legs for doing standing transfers, etc...

Sorry for being awol lately, we moved out of the motor home ( sorry Mark, my brother took it back to Texas) and we moved into a house here.

Between my ssdi and gifts and assistance from friends and family there is no way we would qualify without jumping through a lot of hoops and I don't feel like scattering our expenses among a bunch of people just to qualify.

Again thanks all!
 
[mod note: . . . expectation of improvement is still official policy except for small pilots]

In Jimmo v. Sebelius, a federal court held that Medicare’s "Improvement Standard" is unlawful. The settlement in that case establishes a process of "re-review" for Medicare beneficiaries who received a denial of skilled nursing facility care, home health care, or out-patient therapy services that became final and non-appealable after January 18, 2011 because of the Improvement Standard. The settlement agreement also requires CMS to undertake a comprehensive nationwide Educational Campaign to inform people that Medicare coverage is NOT limited to beneficiaries who have the potential for improvement. So the moderator’s revision to my post runs afoul of the court’s and parties’ express intent to educate the public that the Improvement Standard no longer applies and was never legal in the first place.

On August 18, 2016, the court ordered Medicare to actively inform people they do not have to improve in order to obtain Medicare coverage for necessary care. Just as the court ordered CMS to develop “corrective action” for its inadequate education effort, the moderator’s revision to my post should be removed not only because it is inaccurate and misleading, but because it causes the very harm that the settlement agreement is intended to remedy by requiring the public to be educated that the Improvement Standard is an illegal rule of thumb that does not apply in any case.

The Center for Medicare Advocacy encourages people to appeal if they are told Medicare coverage is not available for skilled maintenance nursing or therapy because they are not improving.
 
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