How does being hospitalized affect my Medicare coverage and health care costs?

Jay JohnsonMedicare Answers0 Comments

Dear Marci,

I am in charge of my father’s care, and he was recently hospitalized as an inpatient. How does his Medicare work for his hospital stay, and what can I do if the hospital wants to release him before I think he’s ready to be discharged?

Julianne (Cary, NC)

Dear Julianne,

If your father is covered by Original Medicare, his inpatient hospital stay is covered by Part A (hospital insurance). How much will Medicare pay for his stay, and what will his costs be? When he is a hospital inpatient, he is responsible for the Part A hospital deductible of $1,316 at the beginning of each benefit period. After he meets the deductible, he pays zero dollars for the first 60 days of inpatient care in each benefit period. He owes a coinsurance of $329 for days 61 through 90 in each benefit period and of $658 per lifetime reserve day he uses after day 90. He has 60 lifetime reserve days that can only be used once. Note that if your father has a Medicare supplemental insurance policy (Medigap plans A through L), it will pay for all his hospital coinsurance plus provide up to 365 additional lifetime reserve days. Medigap plans B through J will also pay his full hospital deductible.

If your father has a Medicare Advantage Plan, contact his plan to learn what its cost sharing rules are for hospital care. Many plans have a deductible and/or daily copayments for inpatient care. Some Medicare Advantage plans use a benefit period similar to Original Medicare, while others assess the inpatient deductible only once per year.

A benefit period begins when someone is admitted to a hospital as an inpatient and ends when they have been out of the hospital or Skilled Nursing Facility (SNF) for at least 60 days in a row. If your father is readmitted to the hospital more than 60 days after his previous inpatient hospital stay, a new benefit period begins. This means that he will have to pay the inpatient hospital deductible again, and his coverage days renew. If he is readmitted to the hospital before 60 days have passed, then he is in the same benefit period. He does not have to pay the inpatient hospital deductible again and his coverage days continue from where he left off.

Medicare Part A covers up to 60 additional lifetime reserve days. These are available when he has used all 90 covered hospital days during a single benefit period. Once again, reserve days are not renewable and can be used only once during a beneficiary’s lifetime.

Your father doesn’t have to use these days if he would prefer not to, and he doesn’t have to use them during the same hospital stay. If he is in the hospital for more than 90 days in a single benefit period, the hospital typically starts using his lifetime reserve days unless he decides that he doesn’t want to use them. If he is in the hospital for an extended stay, the hospital should notify him on day 85 of his hospital stay that he has five covered days left in the benefit period. He can decide to use his lifetime reserve days after day 90 of his hospital stay. If he decides he doesn’t want to use his lifetime reserve days, he must notify the hospital in writing. In that case, Medicare won’t pay toward any hospital costs beyond the standard 90 Medicare-covered days in a benefit period.

If your father’s health care provider decides that he no longer requires hospital care, or believes Medicare will no longer pay for continued care, your father will receive notice from the hospital that he will soon be discharged. If you or your father do not feel that he is ready to leave the hospital, you can appeal the hospital’s decision. Appealing means you ask an outside organization to review the hospital’s decision to discharge your father.

You or your father (or any other representative) can appeal a hospital discharge by following directions on a notice called An Important Message From Medicare, which should also explain why he is being discharged. His doctor can also assist you with the appeal. The Important Message will provide contact information for the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). You must file an appeal with the BFCC-QIO by the date on the notice to protect your father against incurring out of pocket costs. Once you file your appeal, the BFCC-QIO will contact you by phone to discuss your case. These types of appeals are expedited, meaning decisions are made quickly. It is important to be aware of the deadlines for appealing and to keep track of all paperwork you receive. If your first appeal with the BFCC-QIO is not successful, you can continue to appeal by following directions on the unfavorable decision that the BFCC-QIO sends you. You can still appeal once your father has left the hospital, but the appeal will be handled on a standard timeline, instead of an expedited one. For information about how the hospital should help arrange for your father’s post-hospitalization needs, read about hospital discharge planning.

– Marci    

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