Hospital Transitions: What Consumers Should Know 2016

Hospital Transitions: What Consumers Should Know 2016
9/25/2017 Hospital Transitions: What Consumers Should Know 2016

Medicare Rights Center
9/25/2017 Medicare Rights Center The Medicare Rights Center is a national, nonprofit consumer service organization that works to ensure access to affordable health care for older adults and people with disabilities through Counseling and advocacy Educational programs Public policy initiatives © 2016 Medicare Rights Center

National Council on Aging
9/25/2017 National Council on Aging This toolkit for State Health Insurance Assistance Programs (SHIPs), Area Agencies on Aging (AAAs), and Aging and Disability Resource Centers (ADRCs) was made possible by grant funding from the National Council on Aging © 2016 Medicare Rights Center

© 2016 Medicare Rights Center
9/25/2017 Learning objectives Understand Medicare Part A’s coverage of hospital stays Explain your right to discharge planning Know how Medicare covers post-hospital skilled nursing facility (SNF), home health, and hospice care Identify your options for long-term care following a hospital stay © 2016 Medicare Rights Center

9/25/2017 What is Medicare? Health insurance for people age 65+ and many of those who have received Social Security disability benefits for 24 months People of all income levels are eligible Run by the federal government but can be provided by private insurance companies that contract with the federal government © 2016 Medicare Rights Center

Medicare eligibility: Age
9/25/2017 Medicare eligibility: Age Someone 65+ is eligible for Medicare if one of the following conditions is met 1. They either receive or qualify for Social Security retirement cash benefits OR 2. They currently reside in the United States and are either A U.S. citizen or A permanent U.S. resident who has lived in the U.S. continuously for five years prior to applying © 2016 Medicare Rights Center

Medicare eligibility: Disability
9/25/2017 Medicare eligibility: Disability Individuals under 65 are eligible for Medicare if they have been receiving Social Security Disability Insurance (SSDI) for 24 months Individuals are Medicare-eligible the first day of the 25th month of receiving SSDI Exception: Those who receive SSDI because they have Amyotrophic Lateral Sclerosis (ALS) become eligible the first month their SSDI benefits start © 2016 Medicare Rights Center

Medicare eligibility: ESRD
9/25/2017 Medicare eligibility: ESRD Individuals are also eligible for Medicare if they have End- Stage Renal Disease (ESRD) Get dialysis treatments or have had a kidney transplant Have applied for Medicare benefits Have been deemed eligible for SSDI, railroad retirement benefits, or are otherwise considered to be fully insured by Social Security © 2016 Medicare Rights Center

Medicare options: Original Medicare
9/25/2017 Medicare options: Original Medicare Original Medicare Made up of three parts Part A – hospital insurance/inpatient insurance Administered by the federal government Part B – medical insurance/outpatient insurance Part D – prescription drug benefit Provided by private insurance companies © 2016 Medicare Rights Center

Medicare options: Medicare Advantage
9/25/2017 Medicare options: Medicare Advantage Medicare Advantage Also known as Part C Provided by private insurance companies that contract with federal government to provide Medicare benefits Combines Part A, Part B, and usually Part D benefits in the same plan Not a separate benefit © 2016 Medicare Rights Center

Part A hospital care coverage
9/25/2017 Part A hospital care coverage © 2016 Medicare Rights Center

9/25/2017 Hospital coverage If you are a hospital inpatient, Part A covers Semi-private room Meals General nursing Medications Other hospital services and supplies Part A does not cover Private duty nursing Private room, unless medically necessary Personal items (razors, socks) © 2016 Medicare Rights Center

Medicare Part A Costs for 2016 © 2016 Medicare Rights Center
9/25/2017 Part A costs Medicare Part A Costs for 2016 Premium Free if you have10 years of Social Security work history $226 if you or your spouse worked and paid Medicare taxes for 7.5 to 10 years $411 if you or your spouse worked and paid Medicare taxes for fewer than 7.5 years Hospital deductible $1,288 for each benefit period Hospital coinsurance $322 per day for days each benefit period $644 per day for days (these are 60 non-renewable lifetime reserve days) Skilled nursing facility (SNF) coinsurance $161 per day for days each benefit period Extra information about the benefit period: A benefit period begins when a you are admitted to a hospital or skilled nursing facility (SNF) SNF as an inpatient and ends when you have been out of the hospital or SNF for at least 60 days in a row. You must be out of both the hospital and a SNF for 60 days in a row before your benefit period ends. A new benefit period begins if you are readmitted to a hospital more than 60 days after their previous inpatient hospital stay. This means that you pay the inpatient hospital deductible again, and your coverage days renew. If you are readmitted to a hospital before 60 days have passed, then you are in the same benefit period. You do not have to pay the inpatient hospital deductible again and your coverage days continue from where you left off. © 2016 Medicare Rights Center

Medicare Part A Costs for 2017 © 2016 Medicare Rights Center
9/25/2017 Part A costs Medicare Part A Costs for 2017 Premium Free if you have10 years of Social Security work history $227 if you or your spouse worked and paid Medicare taxes for 7.5 to 10 years $413 if you or your spouse worked and paid Medicare taxes for fewer than 7.5 years Hospital deductible $1,316 for each benefit period Hospital coinsurance $329 per day for days each benefit period $658 per day for days (these are 60 non-renewable lifetime reserve days) Skilled nursing facility (SNF) coinsurance $ per day for days each benefit period Extra information about the benefit period: A benefit period begins when a you are admitted to a hospital or skilled nursing facility (SNF) SNF as an inpatient and ends when you have been out of the hospital or SNF for at least 60 days in a row. You must be out of both the hospital and a SNF for 60 days in a row before your benefit period ends. A new benefit period begins if you are readmitted to a hospital more than 60 days after their previous inpatient hospital stay. This means that you pay the inpatient hospital deductible again, and your coverage days renew. If you are readmitted to a hospital before 60 days have passed, then you are in the same benefit period. You do not have to pay the inpatient hospital deductible again and your coverage days continue from where you left off. © 2016 Medicare Rights Center

Hospital discharge planning
9/25/2017 Hospital discharge planning © 2016 Medicare Rights Center

Hospital discharge planning
9/25/2017 Hospital discharge planning You have the right to discharge planning at the end of your hospital stay Process to determine most appropriate post-hospital discharge destination and care plan for patient Key component of preventing hospital re-admissions Your provider should know the basic discharge planning requirements How to screen you to decide if you need a discharge plan How to create the discharge plan © 2016 Medicare Rights Center

Who qualifies for discharge planning?
9/25/2017 Who qualifies for discharge planning? Hospital inpatients Medicare requirements: Hospital screens inpatient to identify those who would be at risk for complications without a discharge plan Hospital provides detailed discharge plan if you meet criteria Hospital outpatients Hospitals are not required to provide discharge planning to outpatients Medicare recommendations Hospital provides discharge planning to all inpatients and outpatients The only way to tell if you are an inpatient is to ask your attending physician. It is important to get confirmation about your official hospital status as inpatient or outpatient because it affects your benefits. Medicare only requires discharge planning screening for inpatients. © 2016 Medicare Rights Center

Discharge planning steps
9/25/2017 Discharge planning steps Hospital should start screening you for the need for a discharge plan when you are formally admitted, or as soon as possible  If hospital decides you need a discharge plan, appropriate hospital staff conduct an evaluation and create plan  Hospital staff share discharge plan with you and/or your caregiver(s)  Reminder: Discharge planning screening is only required for inpatients and is optional for outpatients. Any patient can request to be screened, however, and if the request is made then the hospital must fulfill it and screen the patient to determine if they need a discharge plan.  Discharge plan is implemented © 2016 Medicare Rights Center

Discharge plan screening
9/25/2017 Discharge plan screening Hospital should screen you when you are admitted to decide if you will need a discharge plan If your condition worsens after first screening, you should be screened again © 2016 Medicare Rights Center

Who creates the discharge plan?
9/25/2017 Who creates the discharge plan? Must be developed or supervised by registered nurse, social worker, or other qualified hospital staff If not nurse or social worker, discharge planner must have Previous discharge planning experience Knowledge of the social and physical factors that affect a patient’s functional status at discharge Knowledge of community services and resources © 2016 Medicare Rights Center

Discharge planning evaluation
9/25/2017 Discharge planning evaluation If the hospital decides you need a discharge plan, you will be evaluated for what should be included in your discharge plan Hospital should consider Your functional status and cognitive ability Type of post-hospital care that you needs Availability of required post-hospital health care services Availability and capability of family and/or friends to provide follow-up care in the home © 2016 Medicare Rights Center

Discharge planning evaluation (continued)
9/25/2017 Discharge planning evaluation (continued) Evaluation includes assessment of Your physical, emotional, and social needs Your goals and preferences as you or your caregiver explain them Whether it is realistic for you to return to your pre-hospital environment (home or facility) Hospital must be familiar with local service providers so they can create realistic discharge plans that meet your needs © 2016 Medicare Rights Center

If you are returning home
9/25/2017 If you are returning home Discharge planning evaluation must identify Your ability to care for yourself If there are caregivers who can be trained to provide care Your need for further health care services For example: Follow-up appointments, home health care, physical or occupational therapy, hospice, dialysis, durable medical equipment (DME) Available supportive social services Your need for home modifications, housekeeping, and/or meal services © 2016 Medicare Rights Center

If you are returning to a facility
9/25/2017 If you are returning to a facility Discharge planning evaluation must identify Whether you have a preferred facility Whether facility has capacity for you after hospital stay Your access to insurance coverage for post-hospital care Hospital staff should know Medicare and Medicaid requirements for post-hospital care coverage Should let you know if you will have to pay out of pocket Providers must give you a list of available Medicare- participating skilled nursing facilities (SNFs) that serve the geographic area that you request Medicare recommends that hospitals form partnerships with post-hospital care providers For example: Centers for Independent Living (CILs), aging and disability resource centers (ADRCs) © 2016 Medicare Rights Center

Discharge plan implementation
9/25/2017 Discharge plan implementation Hospital staff shares discharge plan with you and/or your caregiver Medicare requires hospital to arrange for initial implementation If you are returning home you must receive a discharge plan written in simple language It should include a complete list of your medications with dosages and information about how to take them © 2016 Medicare Rights Center

Discharge plan implementation (continued)
9/25/2017 Discharge plan implementation (continued) Hospitals are responsible for making sure you have all needed resources once you leave the hospital If needed, the hospital should provide Training for you and/or a caregiver on how to provide care Referrals to Medicare-approved or in-network home health care agencies, skilled nursing facilities, hospice agencies, and/or durable medical equipment suppliers Referrals to community resources There are different types of Original Medicare and Medicare Advantage providers that affect the cost of services a beneficiary receives. To get services at the lowest cost, a beneficiary should go to a facility that accepts Original Medicare or a facility that is in network for their Medicare Advantage Plan, depending on their coverage. There are three types of Original Medicare providers. Participating providers accept the Medicare-approved amount for services as full payment. Services are cheapest from a participating provider. Non-participating providers accept the Medicare-approved amount for services as payment, but can charge up to 15 percent more for services. Opt-out providers do not contract with the Medicare program at all. They do not get paid by Medicare to provide services and a beneficiary who sees an opt-out provider will pay for the cost of the service entirely out-of-pocket. There are two types of Medicare Advantage providers. In-network providers contract with the plan. Services are cheapest from in-network providers. Out-of-network providers do not work with the plan and a beneficiary may have to pay for the entire cost of the services out of their own pocket. © 2016 Medicare Rights Center

Appealing hospital discharge
9/25/2017 Appealing hospital discharge You can appeal if you think the hospital is making you leave too soon Steps to ask for a review are listed on the Important Message from Medicare notice You should receive the notice within two days of entering the hospital as an inpatient A hospital discharge appeal goes to the Quality Improvement Organization (QIO), an independent body that decides on inpatient discharge appeals Pay close attention to the deadline for requesting an appeal Most QIO decisions are expedited, and the QIO must tell the beneficiary its decision by close of business the day after the appeal is made If appeal is filed on time, hospital cannot charge patient until QIO makes its decision Further levels of review are available More information about appeals Original Medicare hospital discharge appeals: Medicare Advantage hospital discharge appeals: © 2016 Medicare Rights Center

9/25/2017 Post-hospital care This section focuses on coverage and conditions for Original Medicare. Medicare Advantage Plans must cover the same services that Original Medicare does, but may do so with different costs and restrictions. For example, a Medicare Advantage Plan covers skilled nursing facility care, but may not require a patient to spend three days as a hospital inpatient before covering their skilled nursing facility care. © 2016 Medicare Rights Center

Types of post-hospital care
9/25/2017 Types of post-hospital care Medicare coverage includes Outpatient therapy services (Part B) Skilled nursing facility (SNF) care, including skilled nursing and therapy care (Part A) Home health care (Parts A and B) Hospice care (Part A) Medicare does not cover long-term care If you need long-term care you will likely need to get coverage from other sources, such as Medicaid © 2016 Medicare Rights Center

Part B outpatient therapy coverage
9/25/2017 Part B outpatient therapy coverage Part B covers Outpatient physical, occupational, and/or speech therapy Part B covers if You need therapy, and your doctor considers it a safe and effective treatment You need technical skills that a trained therapist can provide or oversee Doctor or therapist sets up plan of treatment before care begins Therapist performs services or directs staff who perform services Doctor or therapist regularly reviews plan of treatment to see if changes are needed © 2016 Medicare Rights Center

9/25/2017 Part A SNF coverage Part A covers Semi-private room and meals Skilled nursing and/or therapy (see next slide) Medically necessary medications Medical supplies and DME Medical social services Ambulance transportation, when necessary Part A covers these if you Have been hospital inpatient for 3 consecutive days prior to SNF stay Enter Medicare-certified SNF within 30 days of leaving hospital Need skilled nursing care 7 days/week or therapy at least 5 days/week © 2016 Medicare Rights Center

9/25/2017 Skilled nursing care Care that needs to be performed by a registered nurse (RN) or licensed practical nurse (LPN) Services may include: Intravenous injections Tube feeding Catheter changes Changing sterile dressings on a wound Training patient and caregiver to perform required tasks Observation and assessment of individual’s condition if they may have complications or their health may worsen Management and evaluation of plan of care © 2016 Medicare Rights Center

Skilled therapy services
9/25/2017 Skilled therapy services Unlike outpatient therapy, covered by Part A 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 Services include Physical therapy Speech-language pathology Occupational therapy © 2016 Medicare Rights Center

Parts A and B home health care coverage
9/25/2017 Parts A and B home health care coverage Parts A and B cover Intermittent skilled nursing care Physical and speech therapy DME and medical supplies Medical social services Home health aide services (personal care), in certain cases Occupational therapy, if skilled care or other therapies needed Parts A and B cover these if you Are homebound Need skilled nursing services and/or therapy Have a face-to-face meeting with a health care professional within 90 days of getting home care or 30 days after getting care Have a doctor certify a plan of home health care every 60 days Receive care from a Medicare-certified home health agency Both Original Medicare Parts A and B cover home health care. Part A covers home health care if a beneficiary has been in the hospital as an inpatient for three days, or if they have been in a skilled nursing facility after a hospital stay. Medicare Part A covers the first 100 days of a beneficiary’s home health care. Any additional days will then be covered by Medicare Part B. If a beneficiary has not been in the hospital and does not qualify for Part A coverage of their home health care, then Part B covers the home health care from the start. © 2016 Medicare Rights Center

Homebound requirement
9/25/2017 Homebound requirement Homebound typically means you need help to leave the home, e.g., crutches, a walker, a wheelchair, another person A doctor decides whether or not someone qualifies as homebound, based on evaluation of their condition over an extended period of time, not on a daily or weekly basis Leaving home for medical treatment and attending a licensed or accredited adult day care or religious service is always permitted © 2016 Medicare Rights Center

Excluded home health care services
9/25/2017 Excluded home health care services Medicare’s home health care benefit does not cover: 24-hour-per-day care at home Most prescription drugs (these are covered by Part D) Meals delivered to someone’s home Prosthetic devices not used under a plan of care Care from a respiratory therapist Personal care by itself Personal care is only covered if you also need skilled nursing or therapy care Housekeeping by itself Housekeeping services are covered if provided during a covered home health aide visit to provide personal care If you are eligible, the Medicare hospice benefit may pay for some of these services © 2016 Medicare Rights Center

Coverage of maintenance services
9/25/2017 Coverage of maintenance services Medicare covers SNF, home health, and outpatient therapy care regardless of whether your condition is temporary or chronic, or whether or not you are improving Improving is not required for a service to be covered– known as the improvement standard Improvement standard cannot be applied when Medicare is determining coverage of claims that require skilled care Although you may hear otherwise, Medicare covers services intended to help you maintain your ability to function or to prevent or slow worsening © 2016 Medicare Rights Center

Part A hospice care coverage
9/25/2017 Part A hospice care coverage Part A covers Doctor services and nursing care Therapy Short-term inpatient care Short-term respite care for caregiver Hospice aide and homemaker services Drugs for pain management and/or symptom control Grief and loss counseling Part A covers these if patient Is certified by a doctor as terminally ill (i.e. a life expectancy of six months or less) Signs a statement electing hospice care instead of curative care Receives care from a Medicare-certified hospice agency Can take place in hospital, nursing home, beneficiary’s home, other health care settings © 2016 Medicare Rights Center

Medicare and long-term care
9/25/2017 Medicare and long-term care Medicare does not cover most long-term care, such as 24-hour-per-day care Meal delivery Help with activities of daily living, if that is the only care a patient needs Care in an assisted living facility or nursing home Individuals who have chronic illness or disability and need extensive long-term support services may need insurance other than Medicare to cover those services © 2016 Medicare Rights Center

Long-term care options
9/25/2017 Long-term care options Medicaid All state Medicaid programs cover nursing home care and home care Income and asset limits Contact local Medicaid office to learn more Program of All-Inclusive Care for the Elderly (PACE) and certain managed care demonstration projects (state-specific) Government program available in some states to individuals with Medicare and Medicaid who meet other state standards Long-term care insurance Provided by private insurance companies Generally covers nursing home care and home care Veterans’ Affairs (VA) benefits Provides long-term care services to some eligible veterans Contact local VA facility to learn more © 2016 Medicare Rights Center

For more information and help
9/25/2017 For more information and help Local State Health Insurance Assistance Program (SHIP) Social Security Administration Medicare 1-800-MEDICARE ( ) Medicare Rights Center National Council on Aging © 2016 Medicare Rights Center 42

9/25/2017 Medicare Interactive Medicare Interactive Web-based compendium developed by Medicare Rights for use as a look-up guide and counseling tool to help people with Medicare Easy to navigate Clear, simple language Answers to Medicare questions and questions about related topics, for example: “How do I choose between a Medicare private health plan (HMO, PPO or PFFS) and Original Medicare?” 2 million annual visits and growing Page 43 © 2016 Medicare Rights Center

Medicare Interactive Pro (MI Pro)
9/25/2017 Medicare Interactive Pro (MI Pro) Web-based curriculum that empowers professionals to better help clients, patients, employees, retirees, and others navigate Medicare Four levels with four to five courses each, organized by knowledge level Quizzes and downloadable course materials Builds on 25 years of Medicare Rights Center counseling experience For details, visit or contact Jay Johnson at or --Helps professionals navigate Medicare issues such as appeals, coordination with other insurance (COBRA, VA benefits, retiree coverage), low-income programs, eligibility and enrollment --Structured as a four-level Core Curriculum: four to five courses in each level Level One: Health Insurance Terms Level Two: Medicare Coverage Rules Level Three: Appeals and Penalties Level Four: Coordination of Benefits --A Special Topics section addresses subjects not covered in the Core Curriculum, such as Medicare's annual open enrollment period, and Medicare from a policy perspective --A free assessment to test your Medicare knowledge and find out which level of MI Pro you should take to start. -- Courses start at $50 each or $200 per level, with discounts available depending on the number of courses/levels you wish to complete and the number of professionals you wish to train Current clients: insurers, labor organizations, community-based organizations, benefits managers © 2016 Medicare Rights Center

9/25/2017 E-newsletter Released every two weeks Clear answers to frequently asked Medicare questions Links to explore topics more deeply Additional resources and health tips Co-branding available Sign up at © 2016 Medicare Rights Center ©2011 Medicare Rights Center

Hospital Transitions: What Consumers Should Know 2016

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Hospital Transitions: What Consumers Should Know 2016

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