1. Hospital Discharge Rights and Appeals
Presented by:
The SHIP National Technical Assistance Center
Welcome to today’s webinar on Hospital Discharge Rights and Appeals. I am Ginny Paulson, Director of the SHIP National Technical Assistance Center – also known as The SHIP TA Center. I will be your host for today’s webinar. Before I introduce you to our speaker, I would like to explain how you can get the PowerPoint for today’s webinar, if you don’t have it already.
June 10, 2015

2. Resources for Today’s Webinar
Available for download in the pre and post webinar s from WebEx
Also available in the password-protected area of in the “Center Services” menu:
> Login > Center Services > Events > Event Archives
Note: You must have a SHIP Staff account to download from the password-protected “Event Archives”
Our process for sharing webinar materials has changed, now that the new password protected area of our website is available.

3. Today’s Speaker Kat Fitzpatrick
Education Coordinator, Medicare Rights Center and SHIP National Technical Assistance Center
Kat Fitzpatrick is responsible for the development of all education-related print and online content at the Medicare Rights Center as well as serving as a trainer. For the SHIP TA Center, she oversees the development of the monthly Medicare Minute materials, presents in webinars, like today’s, and is responsible for the content of Medicare Rights University for SHIPs, available through the SHIP TA Center’s website.

4. What we will cover today
Medicare rules related to hospital discharge
When beneficiaries receive hospital discharge plans
How discharge plans are developed and implemented
Appealing hospital discharges
Medicare coverage of post-hospital care

5. Medicare coverage of hospital care
Inpatient
The beneficiary has been formally admitted as an inpatient into the hospital by an attending physician
The beneficiary’s care is expected to last at least two midnights
Medicare Part A covers most medically necessary inpatient hospital care

6. Medicare coverage of hospital care
Outpatient
The beneficiary has not been formally admitted into the hospital by an attending physician
The beneficiary’s care is expected to last less than two midnights
Medicare Part B covers most medically necessary outpatient hospital care

7. Medicare coverage of hospital care
Why is the inpatient vs. outpatient distinction important for beneficiaries?
Original Medicare will cover post-hospital Skilled Nursing Facility (SNF) care if the beneficiary has had at least a 3-day qualifying inpatient hospital stay and enters the SNF within 30 days of leaving the hospital
Costs may be higher for beneficiaries who receive outpatient hospital care, as opposed to inpatient hospital care
Outpatients may also experience difficulty getting discharge plans and discharge planning services, since Medicare does not require that outpatients receive these services
Note: Medicare Advantage plans may or may not require plan members to have
a 3-day qualifying inpatient hospital stay in order to receive covered, post
hospital SNF care

8. Medicare Rules for Hospital Discharge

9. Medicare hospital discharge guidelines
Hospitals should work with beneficiaries and their caregivers to plan for hospital discharge
Hospitals must provide names of Medicare-certified SNF and home health agencies to beneficiaries before they are discharged
To compare the quality of these providers, visit or call 800-Medicare
Hospitals must provide the Important Message from Medicare Notice to beneficiaries
Provided upon admission and again before discharge
Explains beneficiary rights
Explains hospital rights to appeal a discharge
CMS doesn’t require discharge planning for all inpatients, only some. They have to discharge plan for those who are at risk after discharge.
CMS does not require discharge planning to any outpatients, regardless of health status. It recommends that hospitals provide something, use an abbreviated planning process for observation stays, same-day surgery, and people discharged from the ER.
If a hospital doesn’t develop a discharge plan for every beneficiary, they have to have a process to notify everyone that they can request an evaluation. If a beneficiary requests it, the hospital can’t deny the evaluation. If a doctor requests a discharge plan, hospital must do one.
Medicare Interactive: Your Right to Hospital Discharge Planning

10. Discharge planning requirements
Discharge planning requirements for inpatients:
All hospitals must screen inpatients to identify those who are at risk for complications without a discharge plan
Hospitals must provide a detailed discharge plan if:
The inpatient is screened and found to be at risk for complications without a discharge plan
The inpatient’s physician requests discharge plan OR
The inpatient or caregiver requests a screening, and the screening finds that a discharge plan is needed

11. Discharge planning requirements
Discharge planning requirements for outpatients:
Hospitals are not required to provide discharge planning to outpatients

12. Discharge planning timeline
Discharge planning timeline requirements for inpatients:
Screen inpatients at an early stage of their hospital stay to identify those needing a discharge plan
If the beneficiary’s stay is less than 48 hours, hospitals still need to screen them for discharge planning prior to their discharge
If a beneficiary’s condition worsens and later requires a discharge plan, hospitals must provide one
Note: Medicare will not penalize hospitals as long as the identification process for inpatients that likely need discharge planning occurs at least 48 hours prior to the beneficiary’s discharge and as long as there is no evidence that the planning was delayed due to the hospital’s failure to complete it on a timely basis
Requirements
Inpatient
Hospitals are required to screen inpatients at an early stage of their hospital stay to identify those needing a discharge plan
If the beneficiary’s stay is less than 48 hours, hospitals still need to screen themfor discharge planning prior to their discharge
If a beneficiary’s condition worsens and later requires a discharge plan, hospitals must provide one

13. Discharge planning timeline
Discharge planning timeline requirements for outpatients:
Medicare does not require that outpatient care, such as that provided under observation or in the ER, receives a discharge plan

14. The discharge planning evaluation and plan
Discharge planning must be completed by qualified hospital staff, e.g., nurses, social workers, physicians, therapists
A discharge planning evaluation assesses:
Biopsychosocial needs
Information from beneficiary and caregivers, including preferences and health care goals, capacity for self-care and availability of caregivers and insurance coverage
Feasibility of return to pre-hospital environment
And
Access to insurance coverage for post-hospital care
The biopsychosocial model (abbreviated "BPS") is a general model or approach stating that biological, psychological (which entails thoughts, emotions, and behaviors), and social (socio-economical, socio-environmental, and cultural) factors, all play a significant role in human functioning in the context of disease or illness. It posits that, health is best understood in terms of a combination of biological, psychological, and social factors rather than purely in biological terms.[1] This is in contrast to the biomedical model of medicine that suggests every disease process can be explained in terms of an underlying deviation from normal function such as a virus, gene or developmental abnormality, or injury.

15. The discharge planning evaluation and plan
Post-hospital care options offered depend on:
Beneficiary’s preferences and health care goals
Beneficiary’s capacity for self-care or access to capable caregivers
And
Availability of appropriate services and facilities after a hospital stay, including SNFs, HHAs, and community- based services

16. Implementing a discharge plan
CMS Requirements for Hospital
Written instructions
Updated medication list
In-hospital training
Transfers to post-hospital care
Referrals to home health or hospice agencies
Referrals for follow-up appointments
Referrals to DME suppliers
Referrals to community resources
Information given to post-hospital care providers
Information about local resource providers
CMS Requirements for Hospital
Provide written, understandable discharge instructions with updated medication list and in-hospital training
Arrange transfers to post-hospital care facilities
Refer beneficiary to home health or hospice agencies
Arrange referrals for follow-up appointments with health care providers
Arrange referrals to DME suppliers
Arrange referrals to community resources for non-traditional health services, such as meals services and transportation
Provide timely medical information to post-hospital care providers, including facilities and primary care providers
Supply information about local resource providers, such as Medicaid agencies and Area Agencies on Aging, to support beneficiaries

17. Appealing a Hospital Discharge

18. Hospital discharge appeals
Starting a hospital discharge appeal is the same for Original Medicare as it is for a Medicare Advantage plan
If beneficiaries or their caregivers think they are being asked to leave the hospital too soon, they should follow the instructions to appeal the hospital discharge decision

19. Hospital discharge appeals
Instructions are on the notice a beneficiary receives before discharge, titled Important Message from Medicare:
The appeal must be filed by midnight on the date of discharge
Medicare will pay for the beneficiary’s hospital care while their first level of appeal is decided
The BFCC-QIO should provide a decision within 24 hours of the filing of the appeal
If the BFCC-QIO decides against the beneficiary, beneficiary can take their appeal to the next level
Medicare will only pay for the beneficiary’s hospital care at higher levels of appeal if their appeal is successful
Beneficiary be charged by the hospital for the days they spent in the hospital after their first appeal decision if further appeals are unsuccessful
The upper levels of appeal are slightly different for Original Medicare and Medicare Advantage Plans

20. BFCC-QIO
Beneficiary and Family-Care Centered Quality Improvement Organization (BFCC-QIO), the entity with which inpatient discharge appeals are filed
KEPRO
Livanta
BFCC-QIOs are also responsible for quality control for hospital inpatients and outpatients
Any beneficiary who has received substandard hospital care can lodge a quality of care complaint with the QIO
Last fall, CMS announced a major change in its QIO program. Two Beneficiary and Family-Care Centered QIOs (BFCC-QIO) now handle hospital discharge appeals for the entire nation.
Quality of care complaint may regard readmissions, poor outcomes, or mortality for an inpatient or an outpatient

21. Important Message from Medicare

22. Medicare Coverage Post-Discharge

23. Coordination of care by primary care providers
In the past, Original Medicare has only paid for post-hospital physician office visits and not for administrative tasks to manage a person’s care after they leave the hospital
Now, Medicare pays primary care providers (PCPs) to manage a person’s care at home in the first 30 days after they leave a SNF, hospital, or partial hospitalization program
The new benefit includes a face-to-face visit with the PCP and non-face- to-face communications with the PCP’s office to coordinate care
This benefit is covered under Medicare Part B
Medicare pays 80 percent of a set fee for all care coordination
Beneficiary pays 20 percent of the Medicare-approved amount
Part of the ACA.
For both Inpatient and outpatient.
Onus has typically been on the beneficiary to request and push for this benefit. Docs don’t always know about it or aren’t educating beneficiaries.
Medicare Interactive: Care coordination by a primary care provider after you stay in a hospital or skilled nursing facility

24. Drug coverage after discharge
Prescriptions and drug administration can change when people move to different settings for care
These changes must be reconciled, and Part D plans are supposed to make it simpler for beneficiaries to access medications
Part D plans must cover prescription drug refills before someone is discharged from a hospital or SNF
Part D plans cannot restrict refills when a person is first admitted to a nursing home or when a doctor prescribes a dosage change
Part D plans must provide a temporary supply of non-formulary medications to nursing home residents
Some Part D plans may provide a temporary non-covered drug supply to beneficiaries when they change care settings
3) How are prescription drugs covered in the hospital?
How prescription drugs are covered depends on whether the beneficiary is an inpatient or outpatient. If they are an inpatient, medically necessary medications are covered under Part A. If they are an outpatient, Part B covers drugs prescribed for you during your time in the hospital. However, Part B does not cover drugs routinely taken (maintenance drugs). Many hospitals don’t allow patients to bring these medications with them from home, so beneficiaries have to get the prescriptions through the hospital’s pharmacy. These pharmacies are rarely part of a Part D plan’s network, so the drugs may be covered but at out-of-network prices. Beneficiaries or caregivers pay the hospital directly, and then submit the hospital bill to their Part D plan for reimbursement. Note that the beneficiary is responsible for the difference between what the hospital charged and what the Part D plan pays in addition to any deductibles, copayments, and coinsurances they would normally pay.

25. Skilled Nursing Facility (SNF) care
Part A covers:
Semi-private room and meals
Skilled nursing care and/or therapy
Medications
Medical supplies and equipment
Medical social services and dietary counseling
Ambulance transportation, when necessary
Medicare should cover SNF care if individuals meet Medicare’s requirements:
Have Medicare Part A before they are discharged from the hospital
Need skilled care every day or therapy services 5 days a week, according to their doctor
Get care in a Medicare-certified SNF
Have a qualifying hospital stay
Must provide at least the same SNF benefits as Original Medicare
Costs may be different than Original Medicare
Medicare Advantage plans may:
Cover more days or waive the three-day prior hospitalization requirement
Require individuals to use network facilities
Beneficiaries must follow the plan’s rules for a SNF stay to be covered
They should call their plans to find out the rules for SNF coverage
While the law says they can’t charge more, the Medicare guidance allows plans to charge copays of up to $50 or $100 during the first 20 days but subsequent SNF days cannot have cost-sharing that exceeds original Medicare.
An MA plan must provide coverage of post-hospital extended care services to Medicare enrollees through a home SNF - a nursing facility capable of providing care where the enrollee was cared for prior to his/her hospital stay - if the enrollee elects to receive the coverage through the home SNF

26. Skilled Nursing Facility (SNF) care
Part A coverage applies if all of the following are true:
The patient has been a hospital inpatient for 3+ consecutive days before their SNF stay
The patient entered a Medicare-certified SNF within 30 days of leaving the hospital
The patient needs skilled nursing care 7 days/week or therapy at least 5 days/week
The patient uses a Medicare-certified SNF
A combination of skilled nursing and therapy services will satisfy the "daily basis" requirement if they're provided seven days a week. In other words, a beneficiary may still qualify for SNF coverage even if s/he does not receive skilled nursing services every day of the week.

27. Home health care Part A and/or Part B covers:
Skilled nursing care and skilled therapy services
Home health aide services (personal care)
Medical social services
Medical supplies
DME (covered separately by Part B)
Medicare will help pay for your home care if all four of the following are true:
You need skilled care. This includes skilled nursing care on an intermittent basis. Intermittent means you need care little as once every 60 days to as much as once a day for three weeks (this period can be longer if you need more care but your need for more care must be predictable and finite). This can also mean you need skilled therapy services. Skilled therapy services can be physical, speech or occupational therapy;* and
You are homebound, meaning it takes a considerable and taxing effort to leave your home, for example you need crutches, a walker, a wheelchair or help from another person; and
Your doctor signs a home health certification stating that you qualify for Medicare home care because you are homebound and need intermittent skilled care. The certification must also say that a plan of care has been made for you, and that a doctor regularly reviews it. Usually, the certification and plan of care are combined in one form that is signed by your doctor and submitted to Medicare. 
As part of the certification, doctors must also confirm that they (or certain other providers, such as nurse practitioners) have had a face-to-face meeting with you related to the main reason you need home care within 90 days of starting to receive home health care or within 30 days after you have already started receiving home health care. Your doctor must specifically state that the face-to-face meeting confirmed that you are homebound and qualify for intermittent skilled care.
The face-to-face encounter can also be done through telehealth. In certain areas, Medicare will cover examinations done for you in specific places (doctors offices, hospitals, health clinics, skilled nursing facilities) through the use of telecommunications (such as video conferencing). 
You receive your care from a Medicare-certified home health agency (HHA).
Medicare Advantage plans must follow Original Medicare’s rules for providing you care, but they can impose different costs and restrictions. You may need to choose a home health agency (HHA) that contracts with your Medicare Advantage plan (private health plan) to get care. You may also have to get your plan's prior approval or a referral before receiving home health care. Although Original Medicare does not charge a copayment, some Medicare Advantage plans do.
If no HHA in your plan's network will take you as a patient, call your plan. Your plan must provide you with home health care if your doctor says it is medically necessary.
If no network HHA will take you, but a non-network one will, your plan must pay for your care that you receive from the non-network HHA. If you cannot find an HHA in your area that is able to take you as a patient, talk with your doctor and your plan about other options that are available to you.
Medicare’s home health care benefit does not cover:
24-hour-a-day care at home
most prescription drugs (although this will be covered under Part D)
meals delivered to someone’s home
prosthetic devices not used under a plan of care
care from a respiratory therapist
personal care alone
Personal care is only covered if someone also needs skilled nursing or therapy care
Housekeeping services alone
Housekeeping services are covered if provided during a covered home health aide visit to provide personal care
If they are terminally ill, the Medicare hospice benefit pays for some of these services
Prescription drugs
24-hour a day care at home
Medicare’s home health care benefit is limited. Medicare does not cover many home care services. Medicare home health care does not cover:
To get Medicare drug coverage, you need to enroll in a Medicare Part D plan. You can choose a stand-alone Medicare private drug plan (PDP), or a Medicare Advantage plan with Part D coverage (MA-DP).
Homemaker or custodial care services (i.e. cooking, shopping, laundry)
Meals delivered to your home
To learn more about the Medicare prescription drug benefit, click on the link in the GO TO box.
The Medicare hospice benefit may pay for some of these items and services for people at the end of life.
Unless custodial care is part of the skilled nursing and/or skilled therapy services you receive from a home health aide or other personal care attendant.

28. Home health care
Part A and/or Part B coverage applies if all of the following are true:
The patient is considered homebound
The patient needs skilled nursing services and/or therapy
The patient has an office visit with a health care professional within 90 days of beginning to receive home care or 30 days after care begins
The patient’s doctor regularly reviews a plan of home health care
They patient receives care from a Medicare-certified home health agency
Medicare will help pay for your home care if all four of the following are true:
You need skilled care. This includes skilled nursing care on an intermittent basis. Intermittent means you need care little as once every 60 days to as much as once a day for three weeks (this period can be longer if you need more care but your need for more care must be predictable and finite). This can also mean you need skilled therapy services. Skilled therapy services can be physical, speech or occupational therapy;* and
You are homebound, meaning it takes a considerable and taxing effort to leave your home, for example you need crutches, a walker, a wheelchair or help from another person; and
Your doctor signs a home health certification stating that you qualify for Medicare home care because you are homebound and need intermittent skilled care. The certification must also say that a plan of care has been made for you, and that a doctor regularly reviews it. Usually, the certification and plan of care are combined in one form that is signed by your doctor and submitted to Medicare. 
As part of the certification, doctors must also confirm that they (or certain other providers, such as nurse practitioners) have had a face-to-face meeting with you related to the main reason you need home care within 90 days of starting to receive home health care or within 30 days after you have already started receiving home health care. Your doctor must specifically state that the face-to-face meeting confirmed that you are homebound and qualify for intermittent skilled care.
The face-to-face encounter can also be done through telehealth. In certain areas, Medicare will cover examinations done for you in specific places (doctors offices, hospitals, health clinics, skilled nursing facilities) through the use of telecommunications (such as video conferencing). 
You receive your care from a Medicare-certified home health agency (HHA).
Medicare Advantage plans must follow Original Medicare’s rules for providing you care, but they can impose different costs and restrictions. You may need to choose a home health agency (HHA) that contracts with your Medicare Advantage plan (private health plan) to get care. You may also have to get your plan's prior approval or a referral before receiving home health care. Although Original Medicare does not charge a copayment, some Medicare Advantage plans do.
If no HHA in your plan's network will take you as a patient, call your plan. Your plan must provide you with home health care if your doctor says it is medically necessary.
If no network HHA will take you, but a non-network one will, your plan must pay for your care that you receive from the non-network HHA. If you cannot find an HHA in your area that is able to take you as a patient, talk with your doctor and your plan about other options that are available to you.
Medicare’s home health care benefit does not cover:
24-hour-a-day care at home
most prescription drugs (although this will be covered under Part D)
meals delivered to someone’s home
prosthetic devices not used under a plan of care
care from a respiratory therapist
personal care alone
Personal care is only covered if someone also needs skilled nursing or therapy care
Housekeeping services alone
Housekeeping services are covered if provided during a covered home health aide visit to provide personal care
If they are terminally ill, the Medicare hospice benefit pays for some of these services
Prescription drugs
24-hour a day care at home
Medicare’s home health care benefit is limited. Medicare does not cover many home care services. Medicare home health care does not cover:
To get Medicare drug coverage, you need to enroll in a Medicare Part D plan. You can choose a stand-alone Medicare private drug plan (PDP), or a Medicare Advantage plan with Part D coverage (MA-DP).
Homemaker or custodial care services (i.e. cooking, shopping, laundry)
Meals delivered to your home
To learn more about the Medicare prescription drug benefit, click on the link in the GO TO box.
The Medicare hospice benefit may pay for some of these items and services for people at the end of life.
Unless custodial care is part of the skilled nursing and/or skilled therapy services you receive from a home health aide or other personal care attendant.

29. SNF and Home Health Skilled Care Requirements
Skilled nursing
Care that needs to be given by a registered nurse (RN) or licensed practical nurse (LPN) including:
Intravenous injections
Tube feeding
Catheter changes
Changing sterile dressings on a wound
Skilled therapy
Services that can only be performed safely and correctly by a licensed therapist, and that are reasonable and necessary for treating an illness or injury. These include:
Physical therapy
Speech-language pathology
Occupational therapy OR
Additional skilled nursing services include:
Training beneficiaries and their caregivers to perform required tasks
Observation and assessment of an individual’s condition if they may have complications or worsening health
Management and evaluation of the plan of care
Regarding skilled maintenance services:
Sometimes, providers will not treat a beneficiary because he/ she is not expected to get better. This is called citing the improvement standard.
Medicare covers SNF, home health, and outpatient therapy care regardless of whether the patient’s condition is temporary or chronic, or whether or not the individual is improving.
Although beneficiaries often hear otherwise, Medicare covers services intended to help patients maintain their ability to function or to prevent or slow them from getting worse.
A class action lawsuit against the Department of Health and Human Services was settled in 2013, ensuring the improvement standard cannot be applied by Medicare or plans.

30. Resources for Today’s Webinar
Available for download in the pre and post webinar s from WebEx
Also available for download at
> Login > Center Services > Events > Event Archives
Note: You must have a SHIP Staff account to download from the password-protected “Event Archives”
As a reminder, if you joined our webinar late today, our process for sharing webinar materials has changed, now that the new password protected area of our website is available.

31. Questions? Email post-webinar questions about appeals to:
The production of this webinar was supported by Grant No. 90ST1001 from the Administration for Community Living (ACL). Its contents are solely the responsibility of the SHIP TA Center and do not necessarily represent the official views of ACL.

32. Contact Info
Host: Ginny Paulson, SHIP TA Center: or
Speaker: Kat Fitzpatrick, SHIP TA Center: