Medicare Advice: Important Information about Hospital Coverage - Aging Wisely

The Medicare program is made up of a variety of parts, covering different services from doctor’s visits to medications and acute care needs. To get an overview of the Medicare parts and costs, grab a copy of Aging Wisely’s Medicare Fact Sheet for 2012. hospital and ambulance

Medicare Part A generally covers hospital stays for elders (similar coverage may be provided under Medicare Advantage plans, which are provided by private insurers). Recipients are subject to a flat deductible as their responsibility for a hospital stay up to 60 days (we provide all the costs and details on the Medicare Fact Sheet). Doctors’ services are billed separately, under Medicare Part B.

An important issue for Medicare recipients to understand is the concept of Hospital Observation Services vs. Hospital Admission under Medicare. Staying overnight in the hospital does not automatically mean that one has been admitted, which affects how Medicare covers the costs of the hospital services. Outpatient services are covered under Medicare Part B (like doctor’s services) so when a patient is not admitted, he or she will generally have a 20% copay for each service received. The total costs can exceed the Part A one-time copay.

Additionally, Medicare’s coverage of inpatient rehabilitation is based on a qualifying three-day inpatient hospital stay. Therefore, an individual needing inpatient rehabilitation may find himself footing the bill (many thousands of dollars potentially) for those services.

What can patients and their families do?

Be a strong advocate-ask questions, be aware of this issue so you know to ask if the patient is admitted.
Talk to the physician and case manager about the patient’s circumstances, needs, care planning.
Document who you talk to, information provided.
Consider hiring a professional patient advocate (to navigate the system, help with alternatives, set up after-care and anticipate possible problems, especially needed for long-distance family members).
Seek alternatives if necessary: if patient doesn’t qualify for inpatient rehabilitation at a skilled nursing facility under Medicare, can they be admitted to hospital rehabilitation program, which operates under different parameters? Can Medicare home health services provide sufficient therapy or related services? What other services might be needed if patient goes home to ensure safety?
Find out about your appeal rights. Here is Medicare’s publication on how to file an appeal and where to get help.