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  1. #1

    • Iron-Clad Allie
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    Need Advice From MC Community Over My Critically Ill Mom & Insurance Red Tape

    A MiceChat friend of mine suggested that I post a thread regarding the hassle we are receiving over my critically ill mom's hospitalization.

    We had been taking care of her at home with the assistance of a local outpatient nursing company, and our family doctor. Our doctor is also a pulmanoligist. She had COPD among several other severe conditions and was dependant on an oxygen aperatus, though not a ventilator. Over the past several years she had been in and out of the regular hospital ICUs after having entered thru emergency. She had been in sub acute care nursing homes for short stays a couple of times.

    While at home around five months ago, we had an ambulance take my mom to a hospital emergency room due to her having unsafe trouble with breathing. From there, she was admitted to a room in the hospital's ICU. After several weeks went by, her health improved and she was moved to a less critical area in ICU. She was there for two or three days when she suffered a stroke. subsequently, she was brought back to the main ICU unit (and placed on a ventilator) and then improved enough to be brought back to the lesser "acute care" area again. However, she has remained on a ventilator ever since.

    Our doctor visited and monitored her every day. We, our family and friends also visited her regularly. She hadn't been able to speak since being placed on the ventilator. But, she gradually reached the point of moving both feet and legs, and both hands and arms - although stonger on the left side. She was also making eye contact with us and squeezing our hands in direct response to questions.

    At this point, our doctor decided to ween her off of the vintilator and have her moved to a local long term rehab center that had ventilators. He signed transfer papers at the hospital without realizing that the rehab hospital had been shut down. The regular hospital decided to move her a hundred miles away to another long term hospital. Our doctor protested for three days, but they wouldn't listen to him. They told us to either sign the transfer papers or else pay thousands each day that she remained there. With heavy hearts, we were coerced to sign and my mom was moved. She is no longer close enough for her doctor to take care of her. Instead, she has seven rotating doctors that don't know her or personally care about her.

    For three months, we have been traveling to visit my mom at least once a week - sometimes more than that. We were told 28 days in advance by a hospital administrator that her Midicare would run out. My dad has Blue Cross/ Blue shield coverage and we figured that they would cover her after Medicare lapsed. The 28 day period ended two days prior to Christmas Eve, and we were told by the administrator that they had found a nursing home for my mom. The place was 170 miles from where we live. So, we appealed to Medicare against the move due to the distance. We did so in spite of threats by the administrator to pay over a thousand a day after the bed at the other hospital was no longer available.

    We contacted Medicare again. They told us that they understood our problem, and that the sub acute care hospital the admistrator where my mom is refered to is a nursing home with a ventilator unit. We also contacted Blue Cross/Blue Shield. They had her hospital records sent to them, and have decided to pick up the coverage costs from the day that Medicare stopped. Now, the long term acute care hospital is trying to find a closer sub acute care hospital (with a ventilator unit) to move my mom to. My mom's vitals have improved, and she is breathing partially on her own ..though still on the ventilator. The hospital recently tried to ween her off the ventilator completely, but her blood gasses increased and they had to abandon the effort.

    So, now they intend to make a decision to transfer her to a sub acute care hospital at some point in the near future. They are also telling us that a sub acute care hospital is not a nursing home. We are also being told that Medicare will cover her for the first fifty days. and that Blue Cross would pick up the costs (in part or in full) after that. The administrator at her hospital is advizing us to apply for MediCal for her so that she would be covered by anything that Blue Cross doesn't.

    A problem exists in that Blue Cross had told us that they don't cover custodial care at nursing homes, and that they consider sub acute care hospitals to be nursing homes. The administrator at my mom's hospital said that she believes that Blue cross would pick up the tab in full or in part due to her extenuating circumstance of being dependent on a ventilator.

    Another problem is that my dad and mom were told by MediCal a long while back that she didn't qualify (before we had to bring her to emergency when all of this first started). I believe that it was due to my dad's retirement income being too high.

    So, first of all we want to bring her back to this area. But, the regular hospital that she was at has stated that they do not want her back. there are no sub acute care facilities with a ventilator unit here. A local Kaiser Hospital has ventilator care. But, they have their own insurance plan and do not accept Blue Cross. At this point, I am getting ready to ask legislative representatives to help us look into qualifying for MediCal.

    Any suggestions on what we might do would be greatly appreciated. Her vitals are strong. She is responding by moving her head and making eye contact when we speak to her. She is also moving her hands, arms, feet and legs - and squeezing our hands. WE love her to no end, and all of this hurts. It's all one big mess.

    Kenny - Ride Warrior
    To Boldly Go Where No MiceChatter Has Gone Before!


  2. #2

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    • Skeevy Ray Vaughan
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    Re: Need Advice From MC Community Over My Critically Ill Mom & Insurance Red Tape

    Hiya Kenny I'll try my best.

    I'm assuming since you are talking with both Medicare & Blue Cross/Shield that you have a Suppliment meaning Medicare is the primary insurance and BC/BS is the secondary. If that is the case you should have you choice in acute care facilities that take Medicare.

    It is correct that Nursing/Custodial care is not covered by Medicare or any insurance plan other than a LTC PLan (Long Term Care). The only way to qualify for Medical is to have your parents become "Destitute" which mean they basically have to give away all of their possessions to fall under the federal poverty level (FPL). If they have cars, a house, a pension or other vauable possessions this all counts towards determining whether they are considered "destitute".

    Her medical needs will be taken care of my Medicare but all of these LTC cost will be out of your pocket. The guideline used my medical insurance is treament has to show an improvement in the patient's health over time. Cooking, cleaning, bathing and these items do not help a person's health and therefore is viewed as LTC.

    Kaiser is an option. If you call Kaiser they may have a Medicare "Replacement" policy that you may be able to get for her. Remember, this may just make it more convienent for you because the Acute Care center could be closer. One drawback to that is if you don't like Kaiser you may be stuck with them for a year. Also note, Kaiser will not pay for LTC.

    So in conclusion, you need to find out what the Fedral Poverty Level is and how you get there to qualify for MediCal which would cover LTC. If you put her in a Rest Home your Father's funds will eventually be drained as will your inheritance. Kenny, if you want to talk about this over the phone PM me and I can get more info from you.

    See, I'm not a complete idiot. Occasionally I can be helpful too, who knew!

    Chad

  3. #3

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    Re: Need Advice From MC Community Over My Critically Ill Mom & Insurance Red Tape

    Sorry to hear about your mom's condition, RW. I remember hearing that she was not well. I will keep you folks in my prayers.

    In the mean time,....insurance companies suck. :


    Big props to Aashee for his advice above. ^^^ Kaiser really went above and beyond for my wife, and a story like yours is completely foreign to me from personal experience. Between an incredibly risky surgery to experimental uses of targeted therapies for cancer, massive amounts of pain killers, equipment for use in our home, including TPN pumps, oxygen...you name it... Kaiser was pouring money into trying to find an effective treatment while trying to keep my wife comfortable. I'm sure there may be other stories out there, but I have nothing but positive things to say about Kaiser.

  4. #4

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    • Skeevy Ray Vaughan
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    Re: Need Advice From MC Community Over My Critically Ill Mom & Insurance Red Tape

    Quote Originally Posted by Mac Daddy View Post
    In the mean time,....insurance companies suck. :
    The problem Kenny is having is Medicare related and not an insurance company. In general you may be correct, but in this situation it's just the benefits and they are paying what they are responsible for. The only thing that concerns me is the 100 miles acute care center they are forced to go to but I don't know the situation.

  5. #5

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    Re: Need Advice From MC Community Over My Critically Ill Mom & Insurance Red Tape

    Quote Originally Posted by aashee View Post
    Hiya Kenny I'll try my best.

    I'm assuming since you are talking with both Medicare & Blue Cross/Shield that you have a Suppliment meaning Medicare is the primary insurance and BC/BS is the secondary. If that is the case you should have you choice in acute care facilities that take Medicare.

    It is correct that Nursing/Custodial care is not covered by Medicare or any insurance plan other than a LTC PLan (Long Term Care). The only way to qualify for Medical is to have your parents become "Destitute" which mean they basically have to give away all of their possessions to fall under the federal poverty level (FPL). If they have cars, a house, a pension or other vauable possessions this all counts towards determining whether they are considered "destitute".

    Her medical needs will be taken care of my Medicare but all of these LTC cost will be out of your pocket. The guideline used my medical insurance is treament has to show an improvement in the patient's health over time. Cooking, cleaning, bathing and these items do not help a person's health and therefore is viewed as LTC.

    Kaiser is an option. If you call Kaiser they may have a Medicare "Replacement" policy that you may be able to get for her. Remember, this may just make it more convienent for you because the Acute Care center could be closer. One drawback to that is if you don't like Kaiser you may be stuck with them for a year. Also note, Kaiser will not pay for LTC.

    So in conclusion, you need to find out what the Fedral Poverty Level is and how you get there to qualify for MediCal which would cover LTC. If you put her in a Rest Home your Father's funds will eventually be drained as will your inheritance. Kenny, if you want to talk about this over the phone PM me and I can get more info from you.

    See, I'm not a complete idiot. Occasionally I can be helpful too, who knew!

    Chad
    You are correct, Chad, that Medicare is our primary insurance provider, and Blue Cross/Shield is our Secondary. As you have guestimated, we also have our choice of sub acute care facilities. The acute care facilities are way farther away than the one my mother is in now.

    Blue Cross is covering her where she is now. We've been told that Medicare will cover my mom for the first 50 days completely at a sub acute facility. After that, we would need MediCal to cover the supplemental LTCs. My mom worked hard to help us insure that we have a home and transportation. I need both for my new job which I have worked for years to obtain. She loves me and was ecstatic with pride several months back when she found out that I am getting it. I am planning on having representatives try to help us.

    This is the first that I've heard of Kaiser potentially having a "Replacement" policy. I'll start checking in to that tomorrow. I've admired your intelligence for some time. How nice it is of you to take the time to read our lengthy situational history, and help to untangle the quagmire we are caught up in.

    I'll keep in touch with you. I am PMing you.
    To Boldly Go Where No MiceChatter Has Gone Before!


  6. #6

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    • Skeevy Ray Vaughan
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    Re: Need Advice From MC Community Over My Critically Ill Mom & Insurance Red Tape

    Quote Originally Posted by Ride Warrior View Post
    You are correct, Chad, that Medicare is our primary insurance provider, and Blue Cross/Shield is our Secondary. As you have guestimated, we also have our choice of sub acute care facilities. The acute care facilities are way farther away than the one my mother is in now.

    Blue Cross is covering her where she is now. We've been told that Medicare will cover my mom for the first 50 days completely at a sub acute facility. After that, we would need MediCal to cover the supplemental LTCs. My mom worked hard to help us insure that we have a home and transportation. I need both for my new job which I have worked for years to obtain. She loves me and was ecstatic with pride several months back when she found out that I am getting it. I am planning on having representatives try to help us.

    This is the first that I've heard of Kaiser potentially having a "Replacement" policy. I'll start checking in to that tomorrow. I've admired your intelligence for some time. How nice it is of you to take the time to read our lengthy situational history, and help to untangle the quagmire we are caught up in.

    I'll keep in touch with you. I am PMing you.

    I'm sorry for your situation RW. I'm sad I have to talk with people every now and then in a similar situation.

    A few other questions for you:

    Is this a retirement supplement your Mom is on or an individual plan?

    Do you mind moving to Kaiser? It's a bit of a culture shock for those ussed to PPO plans.

    We'll chat soon, I'm happy to help anyone out because I know the way the Medicare system can be confusing. The government purposely makes it confusing for older people but that's a discussion for the Debate Lounge.


    Good Luck Pal!

  7. #7

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    Re: Need Advice From MC Community Over My Critically Ill Mom & Insurance Red Tape

    Quote Originally Posted by Mac Daddy View Post
    Sorry to hear about your mom's condition, RW. I remember hearing that she was not well. I will keep you folks in my prayers.

    In the mean time,....insurance companies suck. :


    Big props to Aashee for his advice above. ^^^ Kaiser really went above and beyond for my wife, and a story like yours is completely foreign to me from personal experience. Between an incredibly risky surgery to experimental uses of targeted therapies for cancer, massive amounts of pain killers, equipment for use in our home, including TPN pumps, oxygen...you name it... Kaiser was pouring money into trying to find an effective treatment while trying to keep my wife comfortable. I'm sure there may be other stories out there, but I have nothing but positive things to say about Kaiser.
    Great to hear from you over our struggle, Bill. I'm checking with Kaiser tomorrow and will let you know what happens. Kaiser is to be commended for they care given to your wife. As I have said in the past, I believe she remains with you and your children in spirit - and that she is proud of her family. Love truely never dies. Everyone and everyone keeps changing. Exercising our faith is as important as any other form of exercise. It makes us stronger. God only knows ..life is quite a work out.
    To Boldly Go Where No MiceChatter Has Gone Before!


  8. #8

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    Re: Need Advice From MC Community Over My Critically Ill Mom & Insurance Red Tape

    Quote Originally Posted by aashee View Post
    The problem Kenny is having is Medicare related and not an insurance company. In general you may be correct, but in this situation it's just the benefits and they are paying what they are responsible for. The only thing that concerns me is the 100 miles acute care center they are forced to go to but I don't know the situation.
    There are no local acute care facilities with ventilator systems. Kaiser has them, though ..which is much closer to us.
    To Boldly Go Where No MiceChatter Has Gone Before!


  9. #9

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    • Skeevy Ray Vaughan
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    Re: Need Advice From MC Community Over My Critically Ill Mom & Insurance Red Tape

    Quote Originally Posted by Ride Warrior View Post
    There are no local acute care facilities with ventilator systems. Kaiser has them, though ..which is much closer to us.
    Cool. Call me early tomorrow and I'll send you down the right road.

  10. #10

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    Re: Need Advice From MC Community Over My Critically Ill Mom & Insurance Red Tape

    Quote Originally Posted by aashee View Post
    Cool. Call me early tomorrow and I'll send you down the right road.
    Alrighty.
    To Boldly Go Where No MiceChatter Has Gone Before!


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