Hospital Transitions: A Guide for Professionals 2017 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 2017 Medicare Rights Center Page 2
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 2017 Medicare Rights Center Page 3
Learning objectives Understand Medicare Part A s coverage of hospital stays Explain a beneficiary s right to discharge planning Know how Medicare covers post-hospital skilled nursing facility (SNF), home health, and hospice care Identify a beneficiary s options for long-term care following a hospital stay 2017 Medicare Rights Center Page 4
Medicare basics 2017 Medicare Rights Center Page 5
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 2017 Medicare Rights Center Page 6
Medicare eligibility: Age Individual 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 2017 Medicare Rights Center Page 7
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 25 th month of receiving SSDI Exception: Those who receive SSDI because they have ALS become eligible the first month their SSDI benefits start 2017 Medicare Rights Center Page 8
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 2017 Medicare Rights Center Page 9
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 2017 Medicare Rights Center Page 10
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 2017 Medicare Rights Center Page 11
Part A hospital care coverage 2017 Medicare Rights Center Page 12
Hospital coverage If beneficiary is 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) 2017 Medicare Rights Center Page 13
Part A costs Premium Hospital deductible Hospital coinsurance Skilled nursing facility (SNF) coinsurance Medicare Part A Costs for 2017 Free for those with 10 years of Social Security work history $227 if beneficiary or spouse worked and paid Medicare taxes for 7.5 to 10 years $413 if beneficiary or spouse worked and paid Medicare taxes for fewer than 7.5 years $1,316 for each benefit period $329 per day for days 61-90 each benefit period $658 per day for days 91-150 (these are 60 nonrenewable lifetime reserve days) $164.50 per day for days 21-100 each benefit period 2017 Medicare Rights Center Page 14
Hospital discharge planning 2017 Medicare Rights Center Page 15
Hospital discharge planning A beneficiary has the right to discharge planning at the end of their hospital stay Process to determine most appropriate post-hospital discharge destination and care plan for patient Key component of preventing hospital re-admissions Medicare expects providers to have basic knowledge of discharge planning requirements When to screen a patient to determine if they need a discharge plan How to evaluate an individual and develop the discharge plan 2017 Medicare Rights Center Page 16
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 Screening determines inpatient is at risk for complications Inpatient s physician requests discharge plan Inpatient or caregiver requests screening, and screening finds discharge plan is needed Medicare recommendations: Hospital provides detailed discharge planning to all Medicare inpatients 2017 Medicare Rights Center Page 17
Who qualifies for discharge planning? Hospital outpatients Medicare requirements: Hospitals are not required to provide discharge planning to outpatients Medicare recommendations: Hospital provides discharge planning to outpatients Can be shortened discharge plan Especially those who are discharged from observation stays, same-day surgery, or the emergency department 2017 Medicare Rights Center Page 18
Discharge planning steps Hospital should start screening patient for the need for a discharge plan when patient is formally admitted, or as soon as possible If hospital determines patient needs a discharge plan, appropriate hospital staff conduct an evaluation of patient and create plan Hospital staff share discharge plan with patient and/or caregiver(s) Discharge plan is implemented 2017 Medicare Rights Center Page 19
Discharge plan screening Hospital should screen patient when they are admitted to determine if they will need a discharge plan For more complicated cases that may delay screening, Medicare recommends that screening occur within 48 hours before patient is discharged If patient s condition worsens after first screening, they should be screened again 2017 Medicare Rights Center Page 20
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 2017 Medicare Rights Center Page 21
Discharge planning evaluation Patients whose screening reveals a need for discharge plan receive formal evaluation Hospital should consider Patient s functional status and cognitive ability Type of post-hospital care that patient 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 2017 Medicare Rights Center Page 22
Discharge planning evaluation (continued) Evaluation includes assessment of Patient s physical, psychological, and social needs Patient s goals and preferences as explained directly by patient or caregiver Whether it is realistic for patient to return to their prehospital environment (home or facility) Hospital must be familiar with abilities and capacity of local service providers so they can create realistic discharge plans that meet patient needs 2017 Medicare Rights Center Page 23
Patients returning home Discharge planning evaluation must identify Patient s ability for self-care If there are caregivers who can be trained to provide care Patient s 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 Patient s need for home modifications, housekeeping, and/or meal services 2017 Medicare Rights Center Page 24
Patients returning to facility Discharge planning evaluation must identify Whether the patient has a preferred facility Whether facility has capacity for patient after hospital stay Patient s access to insurance coverage for post-hospital care Hospital staff should know Medicare and Medicaid requirements for post-hospital care coverage Should inform patient if they will have to pay out of pocket Providers must give patients list of available Medicareparticipating skilled nursing facilities (SNFs) that serve the geographic area the patient requests Medicare recommends that hospitals form partnerships with post-hospital care providers For example: Centers for Independent Living (CILs), aging and disability resource centers (ADRCs) 2017 Medicare Rights Center Page 25
Discharge plan implementation Hospital staff shares discharge plan with patient and/or caregiver Medicare requires hospital to arrange for initial implementation Patients returning home must receive Easily readable discharge plan Checklists Plain, culturally sensitive language free from jargon or acronyms Legible and complete medication list with drug dosage and administration In-hospital training and education for patient and/or caregiver Teach-back approach: Patient and caregiver explain instructions back to provider to ensure understanding 2017 Medicare Rights Center Page 26
Discharge plan implementation (continued) Hospitals at a minimum must arrange, if needed, the following: Transfer to post-hospital facility that accepts Medicare or is in-network Referrals to nearby home health agencies or hospice providers that accept Medicare or are in-network Referrals to follow-up appointments and DME suppliers Referrals to community resources 2017 Medicare Rights Center Page 27
Documentation requirements Hospital inpatient s file should contain the following Discharge planning evaluation Summary of patient s stay For example: Treatments, symptoms, pain management, whether patient was in seclusion or physically restrained Documentation of conversation about discharge plan that hospital staff member had with the patient/caregiver Copy of the discharge plan 2017 Medicare Rights Center Page 28
Appealing hospital discharge Beneficiaries can appeal if they think the hospital is making them leave too soon Steps to ask for a review are listed on the Important Message from Medicare notice Beneficiary 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 Patients should 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 2017 Medicare Rights Center Page 29
Post-hospital care 2017 Medicare Rights Center Page 30
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 Patients requiring long-term care likely need to get coverage from other sources, such as Medicaid 2017 Medicare Rights Center Page 31
Part B outpatient therapy coverage Part B covers Outpatient physical, occupational, and/or speech therapy Part B covers if Patient needs therapy, and their doctor considers it a safe and effective treatment Patient needs technical skills that 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 2017 Medicare Rights Center Page 32
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 patient Has been hospital inpatient for 3 consecutive days prior to SNF stay Enters Medicare-certified SNF within 30 days of leaving hospital Needs skilled nursing care 7 days/week or therapy at least 5 days/week 2017 Medicare Rights Center Page 33
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 2017 Medicare Rights Center Page 34
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 2017 Medicare Rights Center Page 35
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 patient Is homebound Needs skilled nursing services and/or therapy Has a face-to-face meeting with a health care professional within 90 days of getting home care or 30 days after getting care Has a doctor certify a plan of home health care every 60 days Receives care from a Medicare-certified home health agency 2017 Medicare Rights Center Page 36
Homebound requirement Homebound typically means patient needs help to leave the home, e.g., crutches, a walker, a wheelchair, another person Whether or not someone qualifies as homebound is decided by a doctor s 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 2017 Medicare Rights Center Page 37
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 individual also needs 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 the beneficiary is terminally ill, the Medicare hospice benefit may pay for some of these services 2017 Medicare Rights Center Page 38
Coverage of maintenance services 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 Restoration potential is not needed for a service to be covered The improvement standard cannot be applied when Medicare is determining coverage of claims that require skilled care Although beneficiaries often hear otherwise, Medicare covers services intended to help patients maintain their ability to function or to prevent or slow worsening A class action lawsuit against the Department of Health and Human Services was settled in 2013, ensuring that the improvement standard cannot be applied by Medicare or plans Applies across the country 2017 Medicare Rights Center Page 39
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 2017 Medicare Rights Center Page 40
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 2017 Medicare Rights Center Page 41
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 2017 Medicare Rights Center Page 42
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 2017 Medicare Rights Center Page 43
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