Did you know that 1 in 5 hospital inpatients return to the hospital within 30 days of leaving? To make the transition from the hospital as smooth as possible for you or a loved one, learn about Medicare discharge planning requirements, appeal rights, and coverage of post-hospital care. Below are 3 tips, plus additional action points to make sure you get the hospital care you require while in the hospital and are well prepared with a discharge and post-hospital care plan when you leave.
Point 1: Understand hospital discharge planning and know if you qualify.
Discharge planning helps ensure that you and your caregivers have the information, resources, and care you need as you transition from the hospital to your home or other living arrangement. A discharge plan should identify your post-hospital care needs and the most appropriate next setting for your care. All hospitals must follow certain guidelines when preparing hospital inpatients for discharge. Although Medicare recommends that all inpatients receive an in-depth discharge plan, hospitals must only provide discharge plans to Medicare patients who were screened and found to be at high risk of complications . Keep in mind that Medicare discharge planning requirements and recommendations apply whether you have Original Medicare or a Medicare Advantage Plan. Also, note that Medicare recommends but does not require discharge planning if you are a hospital outpatient.
Point 2: Know how to appeal if you think the hospital is discharging you too soon.
You should appeal the hospital’s decision to discharge you if you think you are being told to leave too soon. To appeal, first consult the Important Message from Medicare notice, which the hospital should provide you at least once during your inpatient hospital stay. Among other things, the notice tells you how to request a review of your case by the Beneficiary and Family-Centered Care Quality Improvement Organization, often called the Quality Improvement Organization (QIO).
To begin the appeal, call the QIO listed on your notice by midnight of the day of your discharge. The QIO should make a decision within 24 hours. If the appeal is successful, you can remain in the hospital, and Medicare or your Medicare Advantage Plan will continue to cover your care. You are not responsible for the cost of your care during this first appeal, even if you are unsuccessful. If you are unsuccessful, there are additional levels of appeal you can use – but you may have to pay for the care you receive if those appeals are unsuccessful.
Point 3: Understand Medicare’s requirements for post-hospital care.
Hospitals must maintain an accurate, up-to-date list of Medicare participating facilities and providers that can provide appropriate post-hospital care. Follow-up care can include placement in nursing homes, skilled nursing facilities, long-term acute care centers, and rehabilitation facilities. If you are returning home, you may get referrals for therapy services, home health care agencies, or hospice care. It is important to understand the coverage requirements for each type of post-hospital care to maximize your coverage and minimize out-of-pocket costs.
Regardless of whether you are being discharged to a facility or to your home, be sure to ask the hospital staff if you qualify for Medicare coverage of follow-up care. If you qualify for a discharge plan, the hospital must arrange transfers to skilled nursing facilities and provide referrals to home health and hospice agencies that accept your Medicare coverage. Hospital staff must also educate you, your family, and/or your caregivers about your care needs if you are returning home, and provide a clear list of instructions for your care, including all medications you will need.
If you are an Original Medicare beneficiary, you will receive a Medicare Summary Notice (MSN) every quarter that lists the health care services you have received during the previous three months, and their costs. Similarly, if you have a Medicare Advantage plan, you will receive periodic Explanation of Benefits (EOB) from your plan, listing the services you have received and their costs. Review your MSN or EOB carefully to make sure the services and provider locations are accurate. If you think you are being held wrongfully responsible for the cost of a service, contact the billing department of your hospital or post-hospital facility to request a correction. If the hospital is uncooperative or if you are still suspicious, call your our California Senior Medicare Patrol – or SMP- program for further assistance at 1-855-613-7080.
Take Action Points:
1) Ask whether you qualify for a discharge plan if you think that it would be helpful to you when you leave the hospital.
2) Appeal the hospital’s decision to discharge you if you think you are being discharged too soon.
3) If you want one-on-one assistance and counseling regarding your hospital transitions – help understanding your discharge plan, the appeals process, or Medicare’s requirements for post-hospital care – contact your local Health Insurance Counseling and Advocacy Program (HICAP) at 800-434-0222.
4) If the billing for your hospital stay is suspicious, contact your SMP for assistance using the contact information below.
This info is taken from the July 2015 Medicare Minute, a program of the Administration on Community Living.