Transcript Document - National Council on Aging

Hospital Transitions:
A Guide for Professionals
2016
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
© 2016 Medicare Rights Center
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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
© 2016 Medicare Rights Center
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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
© 2016 Medicare Rights Center
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Medicare basics
© 2016 Medicare Rights Center
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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
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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
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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 25th month of
receiving SSDI

Exception: Those who receive SSDI because they have ALS
become eligible the first month their SSDI benefits start
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Medicare eligibility: ESRD
 Individuals are also eligible for Medicare if they have EndStage 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
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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
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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
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Part A hospital care
coverage
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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)
© 2016 Medicare Rights Center
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Part A costs
Medicare Part A Costs for 2016
Premium
Free for those with 10 years of Social Security
work history
$226 if beneficiary or spouse worked and paid
Medicare taxes for 7.5 to 10 years
$411 if beneficiary or spouse worked and paid
Medicare taxes for fewer than 7.5 years
Hospital deductible
$1,288 for each benefit period
Hospital coinsurance
$322 per day for days 61-90 each benefit period
$644 per day for days 91-150 (these are 60 nonrenewable lifetime reserve days)
Skilled nursing facility $161 per day for days 21-100 each benefit
period
(SNF) coinsurance
© 2016 Medicare Rights Center
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Part A costs
Medicare Part A Costs for 2017
Premium
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
Hospital deductible
$1,316 for each benefit period
Hospital coinsurance
$329 per day for days 61-90 each benefit period
$658 per day for days 91-150 (these are 60 nonrenewable lifetime reserve days)
Skilled nursing facility $164.50 per day for days 21-100 each benefit
period
(SNF) coinsurance
© 2016 Medicare Rights Center
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Hospital discharge
planning
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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
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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
© 2016 Medicare Rights Center
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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
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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
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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
© 2016 Medicare Rights Center
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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
© 2016 Medicare Rights Center
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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
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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
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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
© 2016 Medicare Rights Center
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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)
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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
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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
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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
© 2016 Medicare Rights Center
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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
© 2016 Medicare Rights Center
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Post-hospital care
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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
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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 a 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
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Part A SNF coverage
 Part A covers


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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
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Skilled nursing care
 Care that needs to be performed by a registered nurse
(RN) or licensed practical nurse (LPN)
 Services may include:


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

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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
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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
© 2016 Medicare Rights Center
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Parts A and B home health care coverage
 Parts A and B cover



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
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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
© 2016 Medicare Rights Center
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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
© 2016 Medicare Rights Center
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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
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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
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Part A hospice care coverage
 Part A covers


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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
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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
© 2016 Medicare Rights Center
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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
© 2016 Medicare Rights Center
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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
© 2016 Medicare Rights Center
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Medicare Interactive
 Medicare Interactive
 www.medicareinteractive.org
 Web-based compendium developed by Medicare
Rights for use as a look-up guide and counseling tool
to help people with Medicare
 Easy to navigate
 Clear, simple language
 Answers to Medicare questions and questions about related
topics, for example:
“How do I choose between a Medicare private health plan
(HMO, PPO or PFFS) and Original Medicare?”
 2 million annual visits and growing
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Medicare Interactive Pro (MI Pro)
 Web-based curriculum that empowers professionals to
better help clients, patients, employees, retirees, and
others navigate Medicare
 Four levels with four to five courses each, organized by
knowledge level
 Quizzes and downloadable course materials
 Builds on 25 years of Medicare Rights Center
counseling experience
 For details, visit www.medicareinteractive.org/learningcenter/courses or contact Jay Johnson at 212-204-6234
or [email protected]
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