Need insurance advice for mom with dementia
March 17, 2010 10:38 AM   Subscribe

Have you ever disenrolled from a HMO (Kaiser) that manages your Medicare to straight Medicare? A lot of people have told me if I do this, it will be easier to find my mom a nursing home. She has dementia/behavior difficulties. Looking for insurance advice specific to California/Medicare/Medi-Cal/dementia nursing homes.

My mom has dementia, advanced Parkinson's, is in a wheelchair, is incontinent, and has a history of psychosis, hallucinations, paranoid, shouting out at night, some aggression, not eating, not taking meds, and not sleeping. She's currently in a Kaiser-contracted psych facility where they're working on straightening out her meds.

I have to find her a new home; her last residential care home (board and care) won't take her back. I'm afraid any new home will kick her out in two months. (Doesn't help that we can only afford $1,500.)

I would love to get her into a dementia unit at nursing care that can deal with her behaviors. She needs to be somewhere with more skilled people, that she can stay at for the rest of her life. There is only ONE such facility in our county that accepts Kaiser and it has no beds.

I have been told by numerous people to disenroll her from Kaiser and that I won't have any problems finding her a place. They say (off the record) Kaiser doesn't pay as much as straight Medicare so that's why there are so few places and that Kaiser does everything they can to avoid paying for skilled nursing.

But I'm scared. I know nothing about Medicare. I don't know if there will be co-pays or if by disenrolling her from Kaiser, I might accidentally disenroll her from any of her Medicare. (I know I have to find a new "Part D" provider.) I don't know if this idea of it being easier is a myth. I'm worried Medi-Cal/Medicare will tell me she only needs custodial care (Kaiser has said this).

Has anyone had experience with this--placing an aged parent in a Medicare/Medi-Cal facility for skilled nursing for dementia? Is it difficult?
posted by faunafrailty to Health & Fitness (2 answers total)
To clarify, does your mom have only Medicare, or is she also enrolled in Medi-Cal (the program run through the state to help with Medicare copays)?

You need to be really, really careful here. Medicare--the federal health insurance program for the elderly--does not cover long-term care services like nursing homes, with a few exceptions.** Medi-Cal, the state program that provides additional assistance to elderly or disabled people, might pay for a nursing home, but it's unclear from your question whether your mom is enrolled in that program.

I wouldn't make any changes until you can find an unbiased source of information on this. Have you tried talking to these people? They're an organization dedicated to helping Medicare beneficiaries figure out their benefits, including long-term care. That would probably be a good place to start if you're trying to understand the options you have for your mom.

Good luck. That sounds tough; I hope you find the information you're looking for.

**Medicare has a limited benefit (like, 20 days of coverage) to pay for skilled nursing home care to recover from an injury or illness, e.g. if you broke your hip and had to spend a few weeks in a nursing home while it healed. It does not cover indefinite care for people who are disabled or frail and can't take care of themselves any more, which sounds like the situation with your mom.
posted by iminurmefi at 11:38 AM on March 17, 2010

Response by poster: My mom is enrolled in Medi-Cal with the long-term care benefit.

I have talked to HICAP last week when Kaiser was trying to release my mom without a place to go, but it's a good idea to call them again. I hadn't thought about it. Thank you.

From what I understand, Medicare will only pay for the short-term nursing care. Once that's up, Medi-Cal will pick up the care but only if she's considered to have a "skilled" need. And I don't know if she will. Thus, my reluctance to get her off Kaiser, but it's not like they'll pay for it either!
posted by faunafrailty at 11:50 AM on March 17, 2010

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