An Important Message From Medicare is an information piece provided to Medicare patients during hospitalization. It is indeed important, but in the avalanche of issues and papers that are part of hospitalization, it may easily be overlooked.
This Medicare message outlines the right to appeal and the process for appealing a hospital discharge decision, when the patient or family believes the individual is not ready for discharge. Taking several important steps will allow for a review of the discharge decision, while maintaining Medicare coverage of hospital costs.
Ask for An Important Message From Medicare, which outlines the following information:
- When facing an impending discharge that you believe is premature, you must ask the hospital (typically a social worker or hospital discharge planner) for written notice explaining the reason for discharge. This notice, the Hospital Issued Notice of Noncoverage (HINN), outlines, from the hospital’s perspective, why the discharge is appropriate. The information on the HINN tells how many days the patient can stay under Medicare coverage and when the patient becomes liable for hospital costs. Do not ask for the HINN until you are upon the determined discharge date, not in advance.
- If you still disagree with the discharge after you receive the HINN notice, you can request a review of the discharge decision. This request must be made by noon the day following receipt of the HINN to ensure continued Medicare coverage during the appeal process. You must make the request to a designated Quality Improvement Organization (QIO), an agency contracted by Medicare to review the appeal. The contact number for the QIO is listed on the HINN.
- The QIO reviews the discharge decision and bases its decision on the medical records of the patient. A determination by the QIO takes place within two days of receiving a request for review by the patient or family.
If the QIO determines that hospital discharge is appropriate, Medicare will cover care until noon on the day following the decision.
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For a patient with a Medicare HMO, the appeals process begins with the hospital but involves different forms and also involves the HMO's own procedures. Again, the process is outlined in An Important Message From Medicare. For the appeal to be considered, care must be taken to follow the procedures and required time frame.
The best time to appeal a decision is when the patient is still in the hospital and the completion of necessary treatment can take place. However, a patient can appeal a decision up until 30 days after hospitalization. Medicare has been established to ensure that all necessary care is provided. The appeals process is in place to protect patients and the Medicare program.
Credit: ElderCare Solutions newsletter
A Primer on Medicaid Coverage of Nursing Home Care
Anyone who considers nursing home care should become familiar with Medicaid, which is the major source of funding for such care.
Medicaid is funded by federal and state governments and administered at the state level; in Illinois, that means by the Department of Human Services. All states must comply with federal requirements, but each state has some discretion in creating eligibility and reimbursement levels. Unlike Medicare, which awards limited nursing home care regardless of income, Medicaid is based on financial need.
Finances are a key consideration in long-term housing decisions with and for the elderly. The cost of nursing home care ranges from $45,000-55,000 yearly. It doesn't take long for savings to be depleted. ElderCare Solutions recommends that families reserve, if possible, enough money for one or two years of nursing home care. A family may want to provide in-home care, but it's ill advised to spend all resources on such care only to find funds depleted if nursing home placement becomes necessary.
Nursing homes limit the number of "Medicaid beds." A nursing home can't deny placement because of payment source, but it may and often does have a long waiting list for people who need to enter the facility under Medicaid. Those beds are taken by residents whose funds have been depleted while in a nursing home.
In Illinois, an individual becomes eligible for Medicaid coverage when all but $2,000 in funds have been depleted. Medicaid allows for prepayment of funeral and burial. Once Medicaid is in place, the recipient is given $30 per month. All other income, including Social Security and pension, is applied to nursing home care cost, with Medicaid making up the difference.
When considering a nursing home, discuss whether the home accepts Medicaid and how a Medicaid bed can be assured when and if private funds are depleted. Most nursing homes will assist the family in the Medicaid application process, but the family must be involved and assume responsibility. If problems develop, the family will ultimately need to solve them.
Applying for Medicaid can be onerous. To avoid the pitfalls and headaches, ElderCare Solutions offers these recommendations:
- Begin the application well in advance. Don't wait until private funds are gone. Carefully account for all income and expenses once an application is submitted.
- The documentation required by the state is extensive. Collect all necessary documents before the application is submitted. An appointment with a caseworker is set up, usually within a few weeks of sending in the application. All documents should be brought to the appointment.
- Respond promptly to all notices sent by the Department of Human Services, even if to say the information is not available. Send all correspondence by certified mail.
- An application for Medicaid can be turned down for "insufficient" information, for materials not provided, or for information submitted after the deadlines. If an application is denied, the decision can be appealed. It is better to appeal a decision than to reapply, since Medicaid payment is based on the application date. If the appeal is successful, payment can be backdated to the original application.
- A number of legitimate and strictly regulated steps can be taken to preserve assets. If considered, asset preservation should be done well in advance of applying for Medicaid and preferably with the help of an elder law attorney.
While the
Medicaid process at times is burdensome and appears arbitrary,
it is important that a thorough review of all documents is undertaken to
ensure the Medicaid system's integrity. However imperfectly we as a society
address the long-term care needs of the elderly, Medicaid not only benefits
the elderly but their families as well.
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Medicare Coverage of Home Health Care
The demand for skilled home health care has increased as the length of hospital stays has decreased. Medicare covers home care when the following conditions are met:
- the care is ordered by a physician;
- the individual is homebound or unable to leave without great effort;
- a licensed professional is needed; and
- the home care agency is licensed by Medicare.
To acquire nursing care under Medicare, the individual must require the assistance of a licensed professional. To be eligible for the care of a speech, occupational or physical therapist, the individual must have rehabilitation potential.
Medicare covers the cost of a home health aide for personal care, such as bathing or dressing, only if the individual requires the services of a licensed provider as well. Medicare does not cover personal care alone.
Medicare pays 80 percent of the approved cost for certain equipment needed at home, such as walkers, commodes and oxygen, when ordered by a physician.
When an elder is under the care of a physician for an acute illness, ask the doctor specifically about home care eligibility. If the elder is hospitalized, meet with the hospital social worker (sometimes known as a "discharge planner") early on to plan effectively for care upon discharge.
A quality home care agency performs an initial assessment and develops a home care plan. Ask to see the care plan and make sure these questions are answered to your satisfaction:
- What are the goals and the expected outcome of the home care to be provided?
- How many times per week will care or therapy be provided and for how many weeks?
- Who will provide the care or therapy?
- How will family members participate in the care?
- Is any teaching of the family incorporated to promote full recovery and prevent recurrence of the illness?
Medicare covers some, but surely not all, home health care needs. ElderCare Solutions encourages you to stay informed and ensure your elder receives all the care to which he or she is entitled.
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Medigap insurance pays some of the deductibles for Medicare-covered services, and may pay for other services not covered by Medicare.
Medigap policies should be purchased during the federally mandated open enrollment period. "The worst mistake seniors are making is not shopping for Medigap during the 'window of opportunity' that Federal law provides," says Martin D. Weiss, president of Weiss Ratings, Inc., an independent organization which evaluates insurers and financial institutions.
The open enrollment period guarantees that for 6 months from the date a senior enrolls in Medicare Part B and is age 65 or older, he or she has the right regardless of any health problems to buy the Medigap policy of choice. A company cannot deny or condition the issuance or effectiveness, or discriminate in the pricing of a policy because of medical history, health status or claims experience. For a policy not purchased during open enrollment, the senior can be charged a higher premium or rejected because of medical problems.
For easier
comparison shopping, most states limit the types of Medigap policies sold
in their jurisdictions to 10 standard plans, designated by letters "A"
though "J." Insurance companies cannot change the combination
of benefits or the letter designations of any plan, and may offer one or
more standard plans. All standard policies are guaranteed renewable.
Because the cost of policies vary widely, comparison shopping is important. Some policies are twice as costly as others for the same coverage. And, lower priced policies are often rated higher by independent organizations than pricier ones.
For more information, call ElderCare Solutions or request the 1997 Guide to Health Insurance for People with Medicare from the Illinois Insurance Department, 800/548-9034.
Credit: ElderCare Solutions newsletter