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Hospital Transitions:
What Consumers Should Know
2016
www.medicarerights.org
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
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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
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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
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Medicare basics
© 2016 Medicare Rights Center
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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
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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
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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
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Medicare eligibility: ESRD
 Individuals are also eligible for Medicare if they have EndStage 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
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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
 Administered by the federal government
 Part D – prescription drug benefit
 Provided by private insurance companies
© 2016 Medicare Rights Center
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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
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Part A hospital care
coverage
© 2016 Medicare Rights Center
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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
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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 61-90 each benefit period
$644 per day for days 91-150 (these are 60 nonrenewable lifetime reserve days)
Skilled nursing facility $161 per day for days 21-100 each benefit
period
(SNF) coinsurance
© 2016 Medicare Rights Center
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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 61-90 each benefit period
$658 per day for days 91-150 (these are 60 nonrenewable lifetime reserve days)
Skilled nursing facility $164.50 per day for days 21-100 each benefit
period
(SNF) coinsurance
© 2016 Medicare Rights Center
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Hospital discharge
planning
© 2016 Medicare Rights Center
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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
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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
 Medicare requirements:
Hospitals are not required to provide discharge planning
to outpatients
 Medicare recommendations
 Hospital provides discharge planning to all inpatients
and outpatients
© 2016 Medicare Rights Center
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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)
Discharge plan is implemented
© 2016 Medicare Rights Center
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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
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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
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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
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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 prehospital 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
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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
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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 Medicareparticipating 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
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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
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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
© 2016 Medicare Rights Center
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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
© 2016 Medicare Rights Center
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Post-hospital care
© 2016 Medicare Rights Center
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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
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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
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Part A SNF coverage
 Part A covers




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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
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Skilled nursing care
 Care that needs to be performed by a registered nurse
(RN) or licensed practical nurse (LPN)
 Services may include:

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
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
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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
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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
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Parts A and B home health care coverage
 Parts A and B cover



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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
© 2016 Medicare Rights Center
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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
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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
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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
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Part A hospice care coverage
 Part A covers




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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
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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
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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 (statespecific)
 Government program available in some states to individuals with
Medicare and Medicaid who meet other state standards
 Contact local Medicaid office to learn more
 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
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For more information and help
 Local State Health Insurance

Assistance Program (SHIP)
 www.shiptacenter.org
 www.eldercare.gov
 Social Security Administration
 1-800-772-1213
 www.ssa.gov
 Medicare
 1-800-MEDICARE (633-4227)
 www.medicare.gov
 Medicare Rights Center
 1-800-333-4114
 www.medicareinteractive.org
National Council on Aging
 www.ncoa.org
 www.centerforbenefits.org
 www.mymedicarematters.org
 www.benefitscheckup.org
© 2016 Medicare Rights Center
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Medicare Interactive
 Medicare Interactive
 www.medicareinteractive.org
 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
© 2016 Medicare Rights Center
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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 www.medicareinteractive.org/learningcenter/courses or contact Jay Johnson at 212-204-6234
or [email protected]
© 2016 Medicare Rights Center
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 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 www.medicarerights.org/aboutmrc/newsletter-signup.php
© 2016 Medicare Rights Center
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