By Barbara Barbero, R.N.
With help from Michele Evans, BSN, CRNH
Who Controls the Money?
The Medicare-type hospice benefit packages usually require that patients "sign over" their medical benefits to the home hospice agency, which then administers them very similarly to an HMO plan. This means that the hospice agency now receives a large portion of your insurance payment dollars from the insurance company.
With this money they must now provide all your home care related to the terminal illness and also pay for all additional care you might receive: pharmacy, medical treatment, hospital and physician or other professional provider bills as long as you remain on hospice. They will, therefore, instruct you to use only providers on a list contracted with the hospice agency. Note that the hospice agency providing your care will have its own contracts for providers of services. These mayor may notbe the same as those which your insurance company had previously approved. So it's always important to refer to the list provided by hospice and ask if you are in doubt. Fortunately, most hospices will usually order and arrange all your care for you with these providers, including all your medical supplies, equipment and devices.
A private physician can be retained and will still be paid by the HMO, Medicare, Medical or your insurance company. Treatment unrelated the terminal illness are still covered by Medicare, HMO and insurance. Medications unrelated to the terminal illness are also still covered by HMO or insurance.
Example: Mr. B has colon cancer with liver metastasis. He also has a history of insulin dependent diabetes. His insulin, endocrinologist and podiatrist would all be covered by his regular insurance, whether HMO, Medicare, or private insurance. This does not apply to Medical.
"Revoking" Hospice Benefits
Hospice benefits have been designed so that you can "revoke" them at any time. Revocation returns you to your regular insurance benefits so that your insurance plan will now pay these bills as they did before you chose hospice. In other words, you can choose to stop your hospice benefits and return to your regular insurance benefits any time and in any situation you choose. No hospice decision is ever permanent!
You can revoke your hospice benefits if you discover that hospice care is not for you. You can't always know until you've tried it.
You can revoke them if you hear of a possible new curative treatment and you want to try it. This is because you can't be on hospice, which is designed for palliative care, if you are taking chemotherapy, for example, which is a treatment intended to work toward a cure or extension of life.
You can revoke hospice if you are dissatisfied with the care you are receiving from the agency you are working with. On the other hand, rather than revoke hospice, you can transfer to another hospice. You can do this one time each certification period, which is described below.
Under Medicare, HMO, or insurance, patients are covered for conditions unrelated to terminal illness. Medical is the only case where the patient must revoke for an unrelated condition if he or she needs hospitalization.
If you have Medical as your only insurance, then you would have to revoke hospice to see other doctors or the hospice may possibly bill you for those services.
So the answer to the situation of the man who possibly broke his leg is fairly simple. Since the wife has the twenty-four hour phone number of the visiting nurse, she can call immediately and discuss the situation. In almost all cases the caregiver has time to call. Only in cases of profuse bleeding, an apparent heart attack or inability to breathe would the caregiver call 911. Even then the hospice agency and insurance company can usually resolve the issue easily.
Note, if you wish to revoke your hospice benefit when your choice is not a medical emergency, you are required to inform the hospice agency before seeking non-hospice care.
What if you were happy with your hospice care and needed to revoke your hospice benefit because you needed a non-hospice type of medical care for a certain period of time? When the non-hospice care is completed, you simply change back to your hospice benefit by notifying your hospice care agency of your wish to resume hospice care. Request them to follow-up with your insurance plan. It's always safe to check directly with your insurance plan to be sure both have recorded the same date of change.
You can continue to alternate between hospice and regular care if the need should arise again. What you can't do is receive the benefits of both hospice and regular insurance at the same time.
What If You Don't Die "On Time"?
The hospice benefit is divided into defined two 90-day time periods and one unlimited period. At the end of the first two periods you, the hospice physician and home care nurse will re-evaluate your medical status and your need for continuing hospital benefits. You can go off hospice at these times and resume hospice care at a later time if needed. You can also revoke hospice and go back to regular benefits between evaluations if you experience a remission or other loss of symptoms.
If you have needed hospice support and at the end of six months you still need itbut are not yet physically ready to diethere are provisions for extending your hospice benefit period. A hospice cannot abandon your care any more than a physician can. Even if the insurance company stops paying the hospice, the hospice must continue to provide needed hospice care. Of course, the doctor's best guess prognosis of six months is requested at the beginning of care and revocation is allowed in order to prevent this from happening frequently. It does occur, however, and if you need extensions you won't be the first.
In summary, hospice benefits were designed to serve and support those people who believe they can or are benefiting from them. They were not created to trick you or to cause your life to end before it is naturally meant to. Hopefully you are clearer now on how you can use hospice benefits and of the flexibility built into them. If you remain unclear, or hear something different from a prospective home hospice agency or your insurance plan, be sure to ask questions and continue asking them until you are certain that you understand your benefits and rights.
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