Ten Facts Seniors Must Know On Leaving the Hospital
Hospitalization brings enough trauma for seniors and their families without considering complicated Medicare and insurance rules. This said, it is critical nonetheless to know some of the basics. Here are ten facts that seniors and their families must know before leaving the hospital.
- You can appeal. This is not to suggest that you should appeal a hospital discharge decision but only to make seniors aware that the appeal option is available. When a patient is not prepared to leave yet either medically or because there is no appropriate placement, questioning regarding appeal rights might slow the process enough to allow for an orderly transition. When dealing with hospital discharge planners, you may be well advised either to be prepared to discuss preferences or to retain someone who can advocate for you. More of this later.
- Your doctor can be your ally. Realistically, decisions regarding discharge involve both medical and insurance determinations. If your physician and health care providers believe you need additional days of hospitalization or if, after discharge, they recommend additional therapy, you are more likely to receive it than if you are requesting this on your own.
- The length of a hospital inpatient stay usually matters for follow-up after leaving the hospital. To receive up to 100 days of rehabilitative treatment either in a rehab facility, a Medicare bed in skilled nursing, or at home, generally speaking you first need inpatient hospitalization for three days. If you receive two days or none, for instance, you do not qualify for this Medicare benefit and would have to pay privately if desired. There are other calculations but this one is basic.
- When calculating three days of inpatient care, consider three “midnights” and make certain the time was spent as an inpatient and not in the emergency room or “under observation”. There can be disagreements in calculating the qualifying three days. If a patient was classified as “under observation” or was in the ER at midnight and not yet admitted, insurers might refuse the benefit for rehabilitation.
- Most patients who have been inpatients for the requisite period should qualify for and receive some rehabilitative treatment after hospitalization. In the past, Alzheimers’ patients with other medical conditions were sometimes denied coverage. Today it is understood that independent determinations must be made regarding whether therapy is needed for physical conditions such as a broken hip or difficulty ambulating (walking).
- Medicare Advantage plans might calculate time periods differently and might try to further limit coverage. Seniors with Medicare Advantage plans need to be especially alert regarding coverage. See “Your doctor can be your ally” above.
- “Up to 100 days” of coverage for rehabilitation does not guarantee 100 days. Up to 100 days of coverage rarely means 100 days. Often insurers discontinue rehabilitation benefits after 2 to 8 weeks. This could be on the basis that the patient has “plateaued” in treatment not showing measurable improvement on a weekly basis, or that the patient has improved to the point that she does not need treatment. When the Medicare rehab period ends, if the resident stays in rehab or in a nursing home, then she must pay privately.
- Going directly home from the hospital could limit future options. A hospital patient who goes home is still entitled to physical and occupational therapy at home but, if this is not enough and it is necessary later to request nursing home placement, this can be more difficult than an admission from a hospital. Also, the applicant would pay privately from the beginning of her stay at a nursing home.
- Specific instructions are needed as to level of care following hospitalization. If, for instance, you are told that your family member needs some assistance but 24 hour a day supervision, you should ask whether this means assisted living or some other interpretation.
- You should control your own placement. When my mother left the hospital many years ago, we had a choice. We could follow the recommendation of a hospital discharge planner or choose one among dozens of listings in a booklet provided to us. We know today that distance, level of care, quality of care, availability of placement, and long term placement all factor into where a hospital patient should go after hospitalization which is why my brother and I began assisting families to make these decisions.
Finally, seniors should know that, after Medicare or the Medicare Supplement or Medicare Advantage plan stops paying, private pay or Medicaid is the next step for additional care and more rules govern these decisions.
About the Author Janet Colliton
Esquire, Colliton Law Associates, P.C. Janet Colliton has practiced law for over 38 years, 37 of them in Chester County, Pennsylvania, a suburb of Philadelphia. Her practice, Colliton Law Associates, PC, is limited to elder law, Medicaid, including advice, applications and appeals, and other benefits planning including Veterans benefits, life care and special needs planning, guardianships, retirement, and estate planning and administration.