Medicare Hospital Coverage and the NOTICE ActMedicare Hospital Coverage and the NOTICE Act

A hospital stay is lot to deal with. You or your loved one may be in pain, worried, and uncertain about what happens next. On top of that, many seniors find that treatments and post-hospital care they assumed would be fully covered by Medicare are not—leaving them responsible for thousands of dollars in co-insurance, prescription costs, and skilled rehabilitation facility expenses.

What keeps these patients from receiving full Medicare coverage? They were listed as under observation during their hospital stay rather than admitted  even in cases when they spent 3 or more nights in the hospital, which is the threshold for full Medicare coverage for in-hospital care and post-hospital rehabilitative care. In some cases, patients assume they’ve been admitted and are blindsided by bills.

This year (2016), after lobbying by patient advocates and senior groups, hospitals nationwide will be required by law to tell patients their status—a change that can help patients save money, appeal their status, and plan for affordable care.

What the NOTICE Act will change for patients

As of August 2016, hospitals must give you written notice of your status (“under observation” or “admitted”) after you’ve been in the hospital for more than 24 hours and before you’ve been under observation for 36 hours. The notice must explain why you haven’t been admitted and how observation status may affect your medical bills, both those incurred during your hospital stay and any prescribed follow-up care in a skilled nursing facility.

In the meantime, what should you do?

If you or a loved one are in the hospital for more than 24 hours, ask for your status and ask the doctors treating you if they plan to recommend skilled nursing care after you leave the hospital. If ‘yes,’ or if you’re under observation for more than a full day, try to persuade the physician or staff to admit you.

If the hospital won’t admit you, the non-profit Center for Medicare Advocacy recommends on its website that you ask your doctor to prescribe home health care. Medicare usually pays for it if you’re homebound and need skilled nursing care. If your doctor decides that’s not a suitable option, CMA advises appealing your case to Medicare. You’ll most likely have to pay the nursing home up front, and the Medicare appeals process is long, so it’s a good idea to start the appeals process as soon as possible.

What NOT to do

One hospital CEO told industry publication Becker’s Hospital News that the number of patients leaving the hospital against medical advice rose when they were told they were under observation rather than admitted. Leaving can be a risky choice, especially if your condition isn’t fully stable. The prospect of high medical bills is daunting, but untreated health conditions can get worse and cost more in the long run.

Where to find help and more information

The Center for Medicare Advocacy’s free Self-Help Packet for Medicare “Observation Status” explains Medicare’s policy and its consequences. It also gives you a step-by-step guide to avoiding observation-status related medical expenses and appealing them if you cannot be admitted. You can also contact the CMA at (860) 456-7790 with questions about the process.

Casey Kelly-Barton is an Austin-based freelance writer whose childhood was made awesome by her grandmothers, great-grandmother, great-aunts and -uncles, and their friends.


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