Hospice and Medicare Advantage Plans - a little known Catch22

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CULater
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Hospice and Medicare Advantage Plans - a little known Catch22

Post by CULater » Tue Apr 09, 2019 10:07 pm

Kind of a long post, but bear with me.

We've been blindsided by an aspect of Medicare coverage for hospice care for my mother that I wanted to post as a "heads up" for folks who may have or be contemplating hospice care for their parent or others. I also have a question.

Here's my story: We were successful in getting mother on hospice care while she was in assisted living and thought that was a wonderful thing because she started getting visits from a hospice nurse twice and week as well as other services, all covered by her Medicare Advantage plan insurance (we thought). But she fell and broke her leg and had to be rushed to the hospital ER, and subsequently hospitalized, treated, and then discharged to a rehab facility. All this treatment cost thousands of dollars, but - not to worry - she had a Medicare Advantage plan that covers all this - right?

We didn't realize anything was amiss until we started receiving huge bills from the ambulance service, the ER, the hospital, physicians, lab, etc etc. After much investigation into the matter, here's what I discovered:

It turns out that if you have a Medicare Advantage plan, on the day you are admitted to hospice care you no longer have it. You now have Original Medicare instead. You don't know that, and your providers don't know that. Consequently, they send the claims to your Medicare Advantage plan and all those claims are denied. You then start receiving the bills from the providers.

What you need to know and the providers need to know (but often don't) is that the claims for a hospice patient have to be submitted to Medicare for payment and not to your Medicare Advantage plan.

What you also need to know is that when they do that, you still end up getting stuck because Medicare will pay only 80% of those Medicare charges and you have no Medicare Supplement insurance (remember, you have a Medicare Advantage plan that is void). So you may end up with hundreds or thousands of dollars in medical bills to pay for your hospice patient who had to be hospitalized or who otherwise may have received medical care that is outside the hospice. For example, we took Mom to a dermatologist for surgical removal of a squamous cell cancer and we ended up with the bills for that.

We had no idea that this is how Medicare Advantage plans and Medicare work when someone is on hospice. Nobody tells you nuttin' So I'm telling you just in case the information might be of use.

Now to my question. After having made sure that all the claims for my mother that were denied were resubmitted to Original Medicare, I'm looking at bills for the balances not paid by Medicare (the deductible, you know). Here's my question: Do I have to pay them or can I just ignore them? Can we be held responsible for charges that we end up with because Mom's Medicare Advantage Plan denied those claims? If the providers who filed claims had those claims denied because they treated a hospice patient, are they not responsible?

I ask this because the skilled nursing facility where Mom went for rehab had their claims denied from her Medicare Advantage plan as well. We were NOT billed by them for those services and were informed that was because the patient was not liable for medical claims filed while she was on hospice -- it was "their error" and they had to eat it. I'd like to know if this is, in fact, the case and we can just forget about the bills we're receiving -- they are effectively non-collectible.
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sport
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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by sport » Tue Apr 09, 2019 10:15 pm

Is this the case for some MA plans or all MA plans?

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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by Stinky » Tue Apr 09, 2019 10:33 pm

Very interesting.

I just checked my MA cert of coverage and I agree with most of what OP says. Quoting my booklet: “Original Medicare (rather than our plan) will pay for your hospice services and any Part A and Part B services related to your terminal prognosis. While you are in the hospice program, your hospice provider will bill original Medicare for the services that original Medicare pays for.”

One thing I don’t know how to interpret is in the “what you must pay” column: “In Network - $0 copay for Medicare-covered hospice consultation services”. So maybe there are services that Medicare Supp policy would provide that my MA plan doesn’t provide.

As I said above, very interesting.
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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by bberris » Wed Apr 10, 2019 7:39 am

Stinky wrote:
Tue Apr 09, 2019 10:33 pm
Quoting my booklet: “Original Medicare (rather than our plan) will pay for your hospice services and any Part A and Part B services related to your terminal prognosis. While you are in the hospice program, your hospice provider will bill original Medicare for the services that original Medicare pays for.”

...
But what if the services are not related to the terminal prognosis, as in the OP mom's case? Does MA cover that?

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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by Stinky » Wed Apr 10, 2019 8:34 am

bberris wrote:
Wed Apr 10, 2019 7:39 am
Stinky wrote:
Tue Apr 09, 2019 10:33 pm
...
But what if the services are not related to the terminal prognosis, as in the OP mom's case? Does MA cover that?
Yes, they are covered under my MA plan.

Quoting again: "If you need non-emergency, non-urgently needed services that are covered under Medicare Part A or B and that are not related to your terminal prognosis .... you pay the plan cost-sharing for in-network or out-of-network services, as the case may be." Also, "If you need non-hospice care, you should contact us to arrange the services."
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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by staythecourse » Wed Apr 10, 2019 8:40 am

Why didn't you just suspend hospice care during the time she was getting treatment for the other issues? That is usually what happens to my patients who go down this route and then develop another issue. Then again, I have not experienced it myself (in the shoes) so maybe they did something different?

Either way, I would talk to your medicare advantage and plain medicare on the best route to handle this. If they are no help talk to the other folks about waiving the 20%. To be honest, if she is in hospice with an obvious short life expectancy who cares and just don't pay the bill. Doesn't the bill just die when she does? Let them file as creditors when she passes.

Good luck.
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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by CULater » Wed Apr 10, 2019 8:56 am

staythecourse wrote:
Wed Apr 10, 2019 8:40 am
Why didn't you just suspend hospice care during the time she was getting treatment for the other issues? That is usually what happens to my patients who go down this route and then develop another issue. Then again, I have not experienced it myself (in the shoes) so maybe they did something different?

Either way, I would talk to your medicare advantage and plain medicare on the best route to handle this. If they are no help talk to the other folks about waiving the 20%. To be honest, if she is in hospice with an obvious short life expectancy who cares and just don't pay the bill. Doesn't the bill just die when she does? Let them file as creditors when she passes.

Good luck.
She was discharged from hospice the day she had to be transported to the ER. However, as it turns out, hospice is month-to-month so it is still in effect for the balance of the month that discharge occurs. She was sent to the ER on the 12th of the month and discharged that day from hospice, which we verified. However, she remained on hospice for the rest of the month and all non-hospice medical charges were denied by her MA plan for that month.
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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by dm200 » Wed Apr 10, 2019 9:20 am

It turns out that if you have a Medicare Advantage plan, on the day you are admitted to hospice care you no longer have it. You now have Original Medicare instead.
So, you are "kicked off" the MA plan/coverage? Sure seems very odd to me. Have you been cited a Medicare rule that this is correct?

I have not recently checked the fine print in my Kaiser medicare plan, but my recollection is that Hospice care is covered.

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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by staythecourse » Wed Apr 10, 2019 9:25 am

CULater wrote:
Wed Apr 10, 2019 8:56 am
staythecourse wrote:
Wed Apr 10, 2019 8:40 am
Why didn't you just suspend hospice care during the time she was getting treatment for the other issues? That is usually what happens to my patients who go down this route and then develop another issue. Then again, I have not experienced it myself (in the shoes) so maybe they did something different?

Either way, I would talk to your medicare advantage and plain medicare on the best route to handle this. If they are no help talk to the other folks about waiving the 20%. To be honest, if she is in hospice with an obvious short life expectancy who cares and just don't pay the bill. Doesn't the bill just die when she does? Let them file as creditors when she passes.

Good luck.
She was discharged from hospice the day she had to be transported to the ER. However, as it turns out, hospice is month-to-month so it is still in effect for the balance of the month that discharge occurs. She was sent to the ER on the 12th of the month and discharged that day from hospice, which we verified. However, she remained on hospice for the rest of the month and all non-hospice medical charges were denied by her MA plan for that month.
Did not know that occurs from discharge of hospice. Can you call the hospice folks and talk to them about what happens in these situations? It happens enough this would not be the first time so they may be able to give you some guidance. Is there a way the hospice could have been suspended instead during that time frame?

I feel like this happens enough there must be a reasonable answer. I wouldn't be surprised if this was one of those things you just need to find the right person to that can answer the correct approach.

I'm sorry you found this out the hard way and am sure others appreciate you letting them know. BUT it is not helpful at this point as there is no plan so far to deal with this. What happened when you talked to the insurers (medicare and your medicare advantage plan)?

Good luck.

p.s. Off all the interesting thing on bogleheads it is odd we don't have a poster who works for medicare or major insurer on coverage issues that can help out. We seem to have experts in nearly EVERY facet of life except this one. Odd.
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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by dm200 » Wed Apr 10, 2019 9:27 am

p.s. Off all the interesting thing on bogleheads it is odd we don't have a poster who works for medicare or major insurer on coverage issues that can help out. We seem to have experts in nearly EVERY facet of life except this one. Odd.

Yes - seems odd to me as well.

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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by fourwheelcycle » Wed Apr 10, 2019 12:11 pm

Very interesting situation to be aware of. My wife and I are not "there" yet, but my wife's mother went through a similar episode, although she was on original Medicare and did have a separate supplemental insurance plan.

Her mother went on hospice care when she became very frail and needed serious pain medication. Hospice was a tremendous resource, visiting her mother in her retirement unit when she encountered problems and advising/reassuring my wife about her mother's care. At one point her mother had a minor stroke and it appeared she could benefit from speech rehab. Hospice said her mother could not receive rehab while enrolled in hospice care and advised she would need to leave hospice if she wanted to do speech rehab, but could re-join hospice when speech rehab had accomplished as much as it could accomplish. Her mother did that, then re-joined hospice, and has now died, very comfortably, with hospice's support.

My wife and I will be going on Medicare next year and we will be considering a Medicare Advantage Plan. I am learning from this thread that we need to ask questions and be aware of what may happen if we ever need hospice care. We would not want to leave Medicare Advantage to join hospice, then require non-hospice services, and be stuck with original Medicare and no supplemental coverage.

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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by dm200 » Wed Apr 10, 2019 12:29 pm

OK - checked my plan docs --

One place:

Hospice – A member who has six months or less to live has the right to elect hospice. We, your plan, must provide you with a list of hospices in your geographic area. If you elect hospice and continue to pay premiums, you are still a member of our plan. You can still obtain all medically
necessary services as well as the supplemental benefits we offer. The hospice will provide special treatment for your state.


Another place:

When you enroll in a Medicare certified hospice program, your hospice services and your Part A and Part B services related to your terminal prognosis are paid for by Original Medicare, not our plan.

Hospice care for members with Medicare Parts A and B You may receive care from any Medicare-certified hospice program. You are eligible for the hospice benefit when your doctor and the hospice medical director have given you a terminal prognosis certifying that you're terminally ill and have six months or less to live if your illness runs its normal course. Your hospice doctor can be a network provider or an out-of-network provider.
Covered services include:
􀀁 Drugs for symptom control and pain relief.
􀀁 Short-term respite care.
􀀁 Home care.
*For hospice services and services that are covered by Medicare Part A or B and are related to your terminal prognosis: Original Medicare (rather than our plan) will pay for your hospice services and any Part A and Part B services related to your terminal prognosis. While you are in the hospice program, your hospice provider will bill Original Medicare for the services that Original Medicare pays for.

For services that are covered by Medicare Part A or B and are not related to your terminal prognosis: If you need non-emergency, non–urgently needed services that are covered under Medicare Part A or B and that are not related to your terminal prognosis, your cost for these services depends on whether you use a provider in our plan's network:


Even though I had actually read all the documents before, I did not notice this.

Thanks for the update.

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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by DB2 » Wed Apr 10, 2019 1:00 pm

I have a question.

When my father passed away in the hospital in 2013, it was going to be his last day there as they were going to transfer him to a hospice the following day. On any rate, despite the fact he had Medicare and an Advantage plan, there was still going to be a modest daily balance for the stay at the hospice. They told my brother and I we would be responsible for that daily balance. They were insistent on it. Of course we were going to pay, but looking back in a less emotional state now, I wonder if they were in any proper legal standing with that demand.

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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by Retired2013 » Wed Apr 10, 2019 2:57 pm

Another little secret.

My mother had a Medicare Advantage plan. I signed her in to hospice at 5:30 pm on a Friday. The MA plan paid all of the services for that day and then 2 months later recalled all of the payments made. Then I started to receive the bills for that days services.

I was told that it didn't matter when I signed her into hospice. All services provided for the whole day is classified as hospice.

The hospital and doctors finally corrected the billings but the Imaging unit, which was not part of the hospital, kept billing. They estate lawyer finally sent them a letter telling them to send it to Medicare or write it off. The estate was not responsible.

After reviewing the form I signed, there was a line that asked what date & time does the hospice take effect. If I knew what I know now, I would have said midnight.

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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by CULater » Wed Apr 10, 2019 4:30 pm

After your hospice benefit starts, you can still get covered services for conditions not related to your terminal illness. Original Medicare will pay for covered services for any health problems that aren’t part of your terminal illness and related conditions. However, you must pay the deductible and coinsurance amounts for all Medicare-covered services you get to treat health problems that aren’t part of your terminal illness and related conditions.
https://www.medicare.gov/pubs/pdf/02154 ... nefits.pdf
If you choose to leave hospice care, your Medicare Advantage Plan won't start again until the first of the following month.
https://www.medicare.gov/what-medicare- ... pice-works

Here's how it was explained to me by the benefits manager at the SNF where my mother went. Medicare Advantage programs are HMOs. Medicare funds MA programs with a flat month-to-month rate. The MA then pays enrollee claims. Medicare funds hospice providers in the same way with a flat month-to-month rate. Medicare will not provide funding for the same individual in more than one provider program, so you must dis-enroll in one in order to receive benefits from the other; e.g, if you are in a MA program you are dis-enrolled when you are enrolled in hospice, and vice versa. However this takes place on an end-of-month basis because of the month-to-month funding by Medicare.

So, you can get caught if you are enrolled in hospice and receive medical services that are not authorized and paid through the hospice. Most typically, hospice will not authorize services that are not related to your hospice diagnosis, or are intended to be curative. Ergo, if you fall and break your leg and are admitted to hospital for treatment you are discharged from hospice. However, this doesn't actually happen until the end of the current month when you are discharged. Meanwhile, your hospital charges are not covered by either hospice or by your MA plan. The charges must be submitted directly to Medicare for payment, and you incur the deductibles and copays for all Medicare-covered services.
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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by celia » Wed Apr 10, 2019 5:49 pm

I was responsible for my uncle who we placed in assisted living (over 10 years ago). When he needed hospice care, I was informed that I could no longer seek preventive care for him, only hospice services. Since we had an upcoming appointment for a second opinion regarding his most serious issue, they told me not to sign up for hospice until after that appointment (and we decided to not pursue any treatments for it). Trying to obtain services for second opinions, preventive care, or anything else to prolong his life runs counter to letting things run the natural course he was already on.
CULater wrote:
Tue Apr 09, 2019 10:07 pm
So you may end up with hundreds or thousands of dollars in medical bills to pay for your hospice patient who had to be hospitalized or who otherwise may have received medical care that is outside the hospice. For example, we took Mom to a dermatologist for surgical removal of a squamous cell cancer and we ended up with the bills for that.
What was the point of going to see this dermatologist, unless skin cancer was the terminal illness she had? It is akin to getting a colonoscopy or tetanus shot. What's the rationale here? My dad is nearing 100 and even the doctors don't push their services any more. He is not going to die from a patch of skin cancer (which he has), even if it spreads. He doesn't want fillings unless the tooth starts hurting. He sees this as wasting services that won't prolong his life. He has bigger health issues and these things are just a waste of his time and money. In fact, some services are not recommended any more, as they could make an infection possible or impact his other health issues.
CULater wrote:
Wed Apr 10, 2019 8:56 am
She was discharged from hospice the day she had to be transported to the ER. However, as it turns out, hospice is month-to-month so it is still in effect for the balance of the month that discharge occurs. She was sent to the ER on the 12th of the month and discharged that day from hospice, which we verified. However, she remained on hospice for the rest of the month and all non-hospice medical charges were denied by her MA plan for that month.
This doesn't make sense from the patient's perspective. So someone who breaks their leg on the first of the month is treated differently than if it happened on the 30th?

I know from the insurance company's viewpoint, insurance starts on the first of the month. So, it seems that you should sign a patient up to start hospice on the first of the month. But that doesn't help the case of someone who breaks a leg or is involved in an accident.
staythecourse wrote:
Wed Apr 10, 2019 9:25 am
p.s. Off all the interesting thing on bogleheads it is odd we don't have a poster who works for medicare or major insurer on coverage issues that can help out. We seem to have experts in nearly EVERY facet of life except this one. Odd.
Not everyone has had a chance to see this thread yet. It just opened up less than 12 hours before your post (while most of us slept during this time). Why do you expect the "experts" to be the first people to read any thread?
DB2 wrote:
Wed Apr 10, 2019 1:00 pm
I have a question.

When my father passed away in the hospital in 2013, it was going to be his last day there as they were going to transfer him to a hospice the following day. On any rate, despite the fact he had Medicare and an Advantage plan, there was still going to be a modest daily balance for the stay at the hospice. They told my brother and I we would be responsible for that daily balance. They were insistent on it. Of course we were going to pay, but looking back in a less emotional state now, I wonder if they were in any proper legal standing with that demand.
Rules change every year. What was in effect in 2013 could very well be different than for today.

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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by staythecourse » Wed Apr 10, 2019 6:41 pm

celia wrote:
Wed Apr 10, 2019 5:49 pm
So, it seems that you should sign a patient up to start hospice on the first of the month.
So if your husband gets terminal cancer on in terrible pain on the 5th of the month you are okay with waiting to next month to start hospice? Of course not.

Good luck.
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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by CULater » Wed Apr 10, 2019 7:23 pm

I was responsible for my uncle who we placed in assisted living (over 10 years ago). When he needed hospice care, I was informed that I could no longer seek preventive care for him, only hospice services. Since we had an upcoming appointment for a second opinion regarding his most serious issue, they told me not to sign up for hospice until after that appointment (and we decided to not pursue any treatments for it). Trying to obtain services for second opinions, preventive care, or anything else to prolong his life runs counter to letting things run the natural course he was already on.
Exactly so. I'm glad that you did receive correct information and advice regarding hospice. Unfortunately, we didn't receive that information from the hospice provider. We had no idea that providing any sort of reasonable care for mother would lead to what we experienced. For example, she continued to receive routine care from the house physician at the assisted living facility. We only learned months later, when the bills started to arrive, that the claims being submitted by the ALF were't being paid. This sort of routine care was really never even reported to us and we didn't really have much awareness since this is the standard operating process at most ALFs and claims were always being routinely paid by her MA plan.
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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by littlebird » Wed Apr 10, 2019 7:36 pm

CULater wrote:
Wed Apr 10, 2019 8:56 am
staythecourse wrote:
Wed Apr 10, 2019 8:40 am
Why didn't you just suspend hospice care during the time she was getting treatment for the other issues? That is usually what happens to my patients who go down this route and then develop another issue. Then again, I have not experienced it myself (in the shoes) so maybe they did something different?

Either way, I would talk to your medicare advantage and plain medicare on the best route to handle this. If they are no help talk to the other folks about waiving the 20%. To be honest, if she is in hospice with an obvious short life expectancy who cares and just don't pay the bill. Doesn't the bill just die when she does? Let them file as creditors when she passes.

Good luck.
She was discharged from hospice the day she had to be transported to the ER. However, as it turns out, hospice is month-to-month so it is still in effect for the balance of the month that discharge occurs. She was sent to the ER on the 12th of the month and discharged that day from hospice, which we verified. However, she remained on hospice for the rest of the month
and all non-hospice medical charges were denied by her MA plan for that month.
When my spouse was on hospice, but had to go to the hospital for a uti, he was discharged from hospice just before leaving for the hospital. He was not on it for the rest of the month. He was put back on the next day when he returned from the hospital. Medicare paid for his hospital bills in the regular way, which they would not have done if he had not been discharged from hospice, or so I was told.

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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by fposte » Wed Apr 10, 2019 7:48 pm

DB2 wrote:
Wed Apr 10, 2019 1:00 pm
I have a question.

When my father passed away in the hospital in 2013, it was going to be his last day there as they were going to transfer him to a hospice the following day. On any rate, despite the fact he had Medicare and an Advantage plan, there was still going to be a modest daily balance for the stay at the hospice. They told my brother and I we would be responsible for that daily balance. They were insistent on it. Of course we were going to pay, but looking back in a less emotional state now, I wonder if they were in any proper legal standing with that demand.
Are you in PA? This doesn’t sound like a Medicare thing, just a medical facility trying a common method of getting a bill paid. There was a successful filial responsibility suit in PA, but even there it was an outlier; more common is the kind of direct approach you encountered. If your father had any assets, they could certainly have claimed against his estate for payment; requiring you two personally to pay would likely be a harder legal sell.

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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by CULater » Wed Apr 10, 2019 7:52 pm

littlebird wrote:
Wed Apr 10, 2019 7:36 pm
CULater wrote:
Wed Apr 10, 2019 8:56 am
staythecourse wrote:
Wed Apr 10, 2019 8:40 am
Why didn't you just suspend hospice care during the time she was getting treatment for the other issues? That is usually what happens to my patients who go down this route and then develop another issue. Then again, I have not experienced it myself (in the shoes) so maybe they did something different?

Either way, I would talk to your medicare advantage and plain medicare on the best route to handle this. If they are no help talk to the other folks about waiving the 20%. To be honest, if she is in hospice with an obvious short life expectancy who cares and just don't pay the bill. Doesn't the bill just die when she does? Let them file as creditors when she passes.

Good luck.
She was discharged from hospice the day she had to be transported to the ER. However, as it turns out, hospice is month-to-month so it is still in effect for the balance of the month that discharge occurs. She was sent to the ER on the 12th of the month and discharged that day from hospice, which we verified. However, she remained on hospice for the rest of the month
and all non-hospice medical charges were denied by her MA plan for that month.
When my spouse was on hospice, but had to go to the hospital for a uti, he was discharged from hospice just before leaving for the hospital. He was not on it for the rest of the month. He was put back on the next day when he returned from the hospital. Medicare paid for his hospital bills in the regular way, which they would not have done if he had not been discharged from hospice, or so I was told.
It sounds like your spouse had Original Medicare insurance and not a Medicare Advantage plan. That's how it would work if you have Medicare. There would be no delay until the end of the month until hospice discharge was effective as there is with a MA plan. And then you would be re-enrolled in hospice after you left the hospital.
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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by littlebird » Wed Apr 10, 2019 8:01 pm

CULater wrote:
Wed Apr 10, 2019 7:52 pm
littlebird wrote:
Wed Apr 10, 2019 7:36 pm
CULater wrote:
Wed Apr 10, 2019 8:56 am
staythecourse wrote:
Wed Apr 10, 2019 8:40 am
Why didn't you just suspend hospice care during the time she was getting treatment for the other issues? That is usually what happens to my patients who go down this route and then develop another issue. Then again, I have not experienced it myself (in the shoes) so maybe they did something different?

Either way, I would talk to your medicare advantage and plain medicare on the best route to handle this. If they are no help talk to the other folks about waiving the 20%. To be honest, if she is in hospice with an obvious short life expectancy who cares and just don't pay the bill. Doesn't the bill just die when she does? Let them file as creditors when she passes.

Good luck.
She was discharged from hospice the day she had to be transported to the ER. However, as it turns out, hospice is month-to-month so it is still in effect for the balance of the month that discharge occurs. She was sent to the ER on the 12th of the month and discharged that day from hospice, which we verified. However, she remained on hospice for the rest of the month
and all non-hospice medical charges were denied by her MA plan for that month.
When my spouse was on hospice, but had to go to the hospital for a uti, he was discharged from hospice just before leaving for the hospital. He was not on it for the rest of the month. He was put back on the next day when he returned from the hospital. Medicare paid for his hospital bills in the regular way, which they would not have done if he had not been discharged from hospice, or so I was told.
It sounds like your spouse had Original Medicare insurance and not a Medicare Advantage plan. That's how it would work if you have Medicare. There would be no delay until the end of the month until hospice discharge was effective as there is with a MA plan. And then you would be re-enrolled in hospice after you left the hospital.
That’s correct

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celia
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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by celia » Wed Apr 10, 2019 8:42 pm

staythecourse wrote:
Wed Apr 10, 2019 6:41 pm
celia wrote:
Wed Apr 10, 2019 5:49 pm
So, it seems that you should sign a patient up to start hospice on the first of the month.
So if your husband gets terminal cancer on in terrible pain on the 5th of the month you are okay with waiting to next month to start hospice? Of course not.
I was saying that from an insurance perspective.

No-one said anything about a patient who needs pain killers, won't be able to get them. Doesn't matter if the patient is in hospice or not. Doesn't matter if the patient has insurance or not.

In fact, even if someone is at the point of needing hospice, she isn't required to be enrolled in it. She just won't get the out-patient visits from the hospice nurse.

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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by Katietsu » Wed Apr 10, 2019 9:13 pm

I found that Medicare Advantage and hospice care was coordinated as described by OP. We delayed signing on to hospice with both my father and FIL for this reason. I found the rules surrounding hospice to be extremely frustrating. Palliative care stepped in a bit to fill part of the gap. But I hope they find a way to improve the system in the future.

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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by DB2 » Wed Apr 10, 2019 10:21 pm

fposte wrote:
Wed Apr 10, 2019 7:48 pm
DB2 wrote:
Wed Apr 10, 2019 1:00 pm
I have a question.

When my father passed away in the hospital in 2013, it was going to be his last day there as they were going to transfer him to a hospice the following day. On any rate, despite the fact he had Medicare and an Advantage plan, there was still going to be a modest daily balance for the stay at the hospice. They told my brother and I we would be responsible for that daily balance. They were insistent on it. Of course we were going to pay, but looking back in a less emotional state now, I wonder if they were in any proper legal standing with that demand.
Are you in PA? This doesn’t sound like a Medicare thing, just a medical facility trying a common method of getting a bill paid. There was a successful filial responsibility suit in PA, but even there it was an outlier; more common is the kind of direct approach you encountered. If your father had any assets, they could certainly have claimed against his estate for payment; requiring you two personally to pay would likely be a harder legal sell.
Not in PA. You may be right about the facility simply trying to getting paid a bill. I think if anything now, maybe it was just a pressure tactic used against us in the situation.

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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by quantAndHold » Thu Apr 11, 2019 12:36 am

DW is a retired hospice nurse. Basically Medicare pays the hospice a fixed rate per day for all the services that hospice provides, and the patient doesn’t have any other health benefits while they’re on hospice. It doesn’t matter whether it’s a Medicare Advantage plan or Medicare A/B. The point of the 30 day rule is to keep people from cycling off and on hospice. Hospice has some desirable benefits that aren’t covered by regular Medicare, and letting people go off hospice to go to ER or a doctor’s visit, and then go right back on, would set up a situation that would be easy to abuse.

The point of hospice is that it provides comfort care for a dying patient and their family. Depending on the patient and the leg, it might make sense to go to the ER to put a cast on a broken leg, but hospitalization, rehab, and skin cancer removal, are all invasive things that we do to keep someone healthy and alive. Usually a person who’s dying doesn’t want or need all of that.

Does mom, the family, the facility and anyone else involved understand what hospice is, and agree that it’s what’s best for her? It sounds like that might not be the case. I know my wife had lots of problems with facilities pulling the rip cord and calling 911 on hospice patients when the family or hospice staff wasn’t around to stop them, but the hospital should have been informed she was a hospice patient, patched the leg up to make her comfortable, and sent her back to the assisted living facility.

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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by Ybsybs » Thu Apr 11, 2019 6:49 am

The statements about the children of patients being liable for medical bills don't ring true to me.

The legal situation I'm familiar with has debts accrue to the patient or the patient's estate.

I'd suggest talking with a lawyer if a bill arrives in your name for a parent's medical care.

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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by staythecourse » Thu Apr 11, 2019 8:17 am

celia wrote:
Wed Apr 10, 2019 8:42 pm
staythecourse wrote:
Wed Apr 10, 2019 6:41 pm
celia wrote:
Wed Apr 10, 2019 5:49 pm
So, it seems that you should sign a patient up to start hospice on the first of the month.
So if your husband gets terminal cancer on in terrible pain on the 5th of the month you are okay with waiting to next month to start hospice? Of course not.
I was saying that from an insurance perspective.

No-one said anything about a patient who needs pain killers, won't be able to get them. Doesn't matter if the patient is in hospice or not. Doesn't matter if the patient has insurance or not.

In fact, even if someone is at the point of needing hospice, she isn't required to be enrolled in it. She just won't get the out-patient visits from the hospice nurse.
Umm, no. You have to be officially enrolled in hospice to get the services of hospice. The reason hospice is chosen is the care is FAR more inclusive then just "getting painkillers".

Good luck.
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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by orlandoman » Thu Apr 11, 2019 8:44 am

Here's the actual Medicare document on this subject https://www.medicare.gov/pubs/pdf/02154 ... nefits.pdf

From page 10:

Hospice care if you’re in a Medicare Advantage Plan or other Medicare health plan

Once you start getting hospice care, Original Medicare will cover everything you need related to your terminal illness, even if you choose to remain in a Medicare Advantage Planor other Medicare health plan.

If you were in a Medicare Advantage Plan before starting hospice care, you can stay in that plan, as long as you pay your plan’s premiums. You can choose to get covered services for any health problems not related to your terminal illness from either your plan or Original Medicare.

What you pay will depend on the plan and whether you follow the plan’s rules, like seeing in-network providers. If your plan covers extra services that aren’t covered by Original Medicare (like dental and vision benefits), your plan will continue to cover these extra services as long as you continue to pay your plan’s premiums and other costs.

- - -

From what I read, above, Medicare covers the hospice, terminal care stuff & your MA plan will cover everything else as it always has, as long as you continue the MA plan.
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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by InMyDreams » Thu Apr 11, 2019 8:47 am

staythecourse wrote:
Thu Apr 11, 2019 8:17 am
Umm, no. You have to be officially enrolled in hospice to get the services of hospice.
The Homecare & Hospice that I worked for offered Palliative services as well as Hospice services. It was the same team of personnel providing these services, but many patients are reluctant to take the Hospice step initially. Palliative services are a way of easing into that service, but is quite similar to hospice, except -
staythecourse wrote:
Thu Apr 11, 2019 8:17 am
The reason hospice is chosen is the care is FAR more inclusive then just "getting painkillers".
Hospice usually implies specific regulatory and reimbursement benefits and requirements. Hospice does not require "homebound" status (homecare and palliative care thru Medicare would); Medicare Hospice is not fee-for-service/pay-per-visit; Medicare Hospice provides service and supplies/medications at no charge to the patient; Medicare Hospice requires grief support to surviving family members for a year after the loss. The list goes on.

Medicare Part D can subsidize the purchase of pain medications while the patient is not on Hospice.

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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by staythecourse » Thu Apr 11, 2019 9:03 am

InMyDreams wrote:
Thu Apr 11, 2019 8:47 am
staythecourse wrote:
Thu Apr 11, 2019 8:17 am
Umm, no. You have to be officially enrolled in hospice to get the services of hospice.
The Homecare & Hospice that I worked for offered Palliative services as well as Hospice services. It was the same team of personnel providing these services, but many patients are reluctant to take the Hospice step initially. Palliative services are a way of easing into that service, but is quite similar to hospice, except -
staythecourse wrote:
Thu Apr 11, 2019 8:17 am
The reason hospice is chosen is the care is FAR more inclusive then just "getting painkillers".
Hospice usually implies specific regulatory and reimbursement benefits and requirements. Hospice does not require "homebound" status (homecare and palliative care thru Medicare would); Medicare Hospice is not fee-for-service/pay-per-visit; Medicare Hospice provides service and supplies/medications at no charge to the patient; Medicare Hospice requires grief support to surviving family members for a year after the loss. The list goes on.

Medicare Part D can subsidize the purchase of pain medications while the patient is not on Hospice.
Correct. Palliative care is covered under normal insurance, but hospice is not the same treatment under insurance. The question was about hospice. There should be better education for folks and providers on the differences and similarities between palliative care and hospice as the insurance implications are different.

Good luck.
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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by AnnieMfuse » Thu Apr 11, 2019 9:34 am

So sorry about these billing catch-22's. [Political comment removed by moderator oldcomputerguy]

With both parents, we were excessively billed and had duplicate bills from doctors and nursing home. It was a nightmare sorting it out.

I am sure your estate lawyer has told you this: only the estate is liable for debts, not any family members. If the estate has spent down and there are insufficient finds, the debts can't be collected. There is a legal order to spending down remaining assets. Estate administration fees are paid before debts. Family inheritance comes only after debts are paid.

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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by Spirit Rider » Thu Apr 11, 2019 9:36 am

Ybsybs wrote:
Thu Apr 11, 2019 6:49 am
The statements about the children of patients being liable for medical bills don't ring true to me.

The legal situation I'm familiar with has debts accrue to the patient or the patient's estate.

I'd suggest talking with a lawyer if a bill arrives in your name for a parent's medical care.
The majority of states have "filial responsibility" laws. Children can be held responsible for the health and welfare of their parents.

Usually, these laws are only used in exceptional situations for their support while living. For example, the children have a luxury lifestyle, yet their parents are indigent, on welfare, food stamps, etc... Some states may sue the children to reimburse the state for such payments.

However, PA and to a lesser degree NJ are particularly aggressive in allowing commercial entities to sue the children for unpaid medical debts. These have been for nursing home or end of life care. It is usually bad actors that get precedent set.

The one case I remember was an affluent mother with plenty of assets to pay. Returned to her Homeland with her assets and skipping out on massive nursing home or medical debt. The court agreed to assign filial responsibility to the children.

Later cases were not so egregious, but precedence had been set.

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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by Cody » Thu Apr 11, 2019 10:15 am

Thank you all so much for this important discussion.

Cody

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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by dm200 » Thu Apr 11, 2019 10:30 am

staythecourse wrote:
Thu Apr 11, 2019 9:03 am
InMyDreams wrote:
Thu Apr 11, 2019 8:47 am
staythecourse wrote:
Thu Apr 11, 2019 8:17 am
Umm, no. You have to be officially enrolled in hospice to get the services of hospice.
The Homecare & Hospice that I worked for offered Palliative services as well as Hospice services. It was the same team of personnel providing these services, but many patients are reluctant to take the Hospice step initially. Palliative services are a way of easing into that service, but is quite similar to hospice, except -
staythecourse wrote:
Thu Apr 11, 2019 8:17 am
The reason hospice is chosen is the care is FAR more inclusive then just "getting painkillers".
Hospice usually implies specific regulatory and reimbursement benefits and requirements. Hospice does not require "homebound" status (homecare and palliative care thru Medicare would); Medicare Hospice is not fee-for-service/pay-per-visit; Medicare Hospice provides service and supplies/medications at no charge to the patient; Medicare Hospice requires grief support to surviving family members for a year after the loss. The list goes on.
Medicare Part D can subsidize the purchase of pain medications while the patient is not on Hospice.
Correct. Palliative care is covered under normal insurance, but hospice is not the same treatment under insurance. The question was about hospice. There should be better education for folks and providers on the differences and similarities between palliative care and hospice as the insurance implications are different.
Good luck.
OK - please "educate" me about the difference - maybe an example or two.

I think about my late uncle. In his mid 80's, he (do not know all the details) was ill and diagnosed with some kind of cancer, BUT it was not know what kind. My brother and father dealt with this. Considering all the facts, circumstances and his desires, he came home (lived with my father) and received no further evaluation and treatment. My brother helped as well (lived next door). They had a nurse come in several times a week as well as some other kind of caregiver a few times a week - to make him as comfortable as possible. As best we know, he was never in significant pain during his last few months. He died, peacefully I believe, one evening when my father was out for a few hours. I do not believe there was any kind of "Hospice" involved - nor (as best I know) any large medical bills for his final months. To me, his situation is very like "hospice" - but without an actual "hospice". Or, was this "palliative care"?

I have concluded that my late uncle's situation was able to be handled this way for several reasons:
1. My brother and father well knew my uncles situation and what he wanted or would have wanted
2. My uncle never married - so no spouse involved
3. My brother's wife is, and has been, very informed about he laws, regulations about care of those approaching death
4. The home situation (with my father and brother next door) was able to handle this.

About ten years later, my father's health deteriorated a lot - and, while he was hospitalized for the final time, my brother and his wife stayed "up to date" on what should and should not be done as my father approached death.

From what I have observed from other elderly folks in their last months and days, most seem to receive a lot more medical things done to and for them - perhaps prolonging "life" - but perhaps in pain and no "quality of life" at all. All this results in very large medical expenses.

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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by quantAndHold » Thu Apr 11, 2019 11:07 am

Hospice and palliative care are similar, but palliative care patients can also get life saving treatment for their condition. DW’s hospice did both. The treatment was similar, but the hospice insurance benefit usually covers a number of things that palliative care doesn’t cover. Basically, everything hospice related, from durable medical equipment (beds, wheelchairs, etc), to supplies, to home visits by doctors, nurses, home care workers, family counseling, is all covered on hospice without a copay. Palliative care is usually covered by the patients regular insurance, and has the same limits and copays as anything else.

When Dad went on hospice, a bunch of things he had been paying for out of pocket, like copays for his oxygen, and people to set up his meds, and the meds hemselves, were covered 100%. There were multiple people in and out of his place every day, and we never saw any kind of bill They also provided a hospital bed and wheelchair in his home. Basically, he went from paying several hundred dollars per month for stuff related to his condition, to zero for the last couple of months, for better care than he had before. My brother and I also became eligible for free grief counseling, not that we used it.

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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by Ybsybs » Thu Apr 11, 2019 11:22 am

Spirit Rider wrote:
Thu Apr 11, 2019 9:36 am
Ybsybs wrote:
Thu Apr 11, 2019 6:49 am
The statements about the children of patients being liable for medical bills don't ring true to me.

The legal situation I'm familiar with has debts accrue to the patient or the patient's estate.

I'd suggest talking with a lawyer if a bill arrives in your name for a parent's medical care.
The majority of states have "filial responsibility" laws. Children can be held responsible for the health and welfare of their parents.

Usually, these laws are only used in exceptional situations for their support while living. For example, the children have a luxury lifestyle, yet their parents are indigent, on welfare, food stamps, etc... Some states may sue the children to reimburse the state for such payments.

However, PA and to a lesser degree NJ are particularly aggressive in allowing commercial entities to sue the children for unpaid medical debts. These have been for nursing home or end of life care. It is usually bad actors that get precedent set.

The one case I remember was an affluent mother with plenty of assets to pay. Returned to her Homeland with her assets and skipping out on massive nursing home or medical debt. The court agreed to assign filial responsibility to the children.

Later cases were not so egregious, but precedence had been set.
I am aware of the filial responsibility laws. I'm also aware of creditors sometimes trying to bill people they can't legally collect from in an attempt to get paid more than they anticipate getting from an estate. I've found consulting with a lawyer to be very helpful and encourage others not to assume that they themselves are obliged to pay for services that they themselves did not receive or authorize.

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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by cashmoney » Thu Apr 11, 2019 11:23 am

If on a medicare advantage plan before hospice starts this is how its it suppose to work...

all hospice related cost are paid by original medicare at 100%.Although it is the providers responsibility to bill medicare they may not be aware of the fact that a person is on hospice unless you tell them.

any medicare covered but not hospice related claims can be either submitted to MA plan where you would pay applicable copays of plan for in network providers or claims can be submitted to original medicare and you would pay the 20% coinsurance after the part B 185.00 deductible is met.Non medicare covered services covered under the MA plan such as dental,vision,hearing etc would still be covered by the MA plan 100%

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CULater
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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by CULater » Thu Apr 11, 2019 2:17 pm

Here's a good summary of how claims must be submitted for a Medicare Advantage plan member who is on hospice:

1. If the service is related to the member’s terminal condition, submit the claim to the regional hospice program.

2. If the service is not related to the member’s terminal condition, submit the claim to Original Medicare.

3. If the service is not covered under Original Medicare, but is a service offered as an enhanced benefit under the member’s Medicare Advantage Plan, submit the claim to the member’s Medicare Advantage plan. Enhanced benefits include:
 Routine vision
 Hearing aids
 Routine dental
 Chiropractic services (only if an Explanation of Medical Benefit denial is present)

4. If a member revokes or is discharged from the hospice benefit:
 Whether a member revokes or is no longer qualified for hospice, continue to send claims to Original Medicare until the end of the month in which the member is no longer qualified for hospice services.
 Claims will continue to be paid by Original Medicare until the first day of the month following the revocation date, or until the end of the month in which they are no longer qualified for hospice service.

5. When a member elects hospice, Original Medicare takes effect on that day and all hospice services on or after the effective date should be billed to either Original Medicare or the regional hospice program (see #1 and #2 above), except any enhanced benefits (see #3 above) offered under the Medicare Advantage program.

https://www.excellusbcbs.com/wps/wcm/co ... 048e49f08

This issue stems from the fact that hospice benefits are not provided currently by Medicare Advantage plans. Consequently, when you enroll in hospice your medical claims (except for the extended benefits of the MA plan) cannot be submitted to your MA plan but must be submitted to Original Medicare either through the hospice (for claims related to your hospice diagnosis) or directly to Medicare (for claims not related to your hospice diagnosis).

If you are on Original Medicare, the problem does not exist.
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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by dm200 » Thu Apr 11, 2019 3:45 pm

quantAndHold wrote:
Thu Apr 11, 2019 11:07 am
Hospice and palliative care are similar, but palliative care patients can also get life saving treatment for their condition. DW’s hospice did both. The treatment was similar, but the hospice insurance benefit usually covers a number of things that palliative care doesn’t cover. Basically, everything hospice related, from durable medical equipment (beds, wheelchairs, etc), to supplies, to home visits by doctors, nurses, home care workers, family counseling, is all covered on hospice without a copay. Palliative care is usually covered by the patients regular insurance, and has the same limits and copays as anything else.

When Dad went on hospice, a bunch of things he had been paying for out of pocket, like copays for his oxygen, and people to set up his meds, and the meds hemselves, were covered 100%. There were multiple people in and out of his place every day, and we never saw any kind of bill They also provided a hospital bed and wheelchair in his home. Basically, he went from paying several hundred dollars per month for stuff related to his condition, to zero for the last couple of months, for better care than he had before. My brother and I also became eligible for free grief counseling, not that we used it.
Thank you.

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Re: Hospice and Medicare Advantage Plans - a little known Catch22

Post by InMyDreams » Fri Apr 12, 2019 8:24 pm

quantAndHold wrote:
Thu Apr 11, 2019 11:07 am
Hospice and palliative care are similar, but palliative care patients can also get life saving treatment for their condition.
+1
When a patient enters the Hospice program (and elects to use his insurance's Hospice Benefit), s/he commits to withdrawing from treatment that might stop or slow the progression of the terminal illness. For example, a patient who had been receiving chemotherapy would (usually) stop receiving that treatment. Radiation therapy would also usually stop, but might be done if it offered relief from pain related to the illness.

As already mentioned, a patient may also go off of Hospice. Unlike what is sometimes seen on dramas, you can change your mind!

Hospice and Palliative care both focus on treatment that reduce or eliminate a patient's discomfort (nausea, pain, anxiety,and so on).

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