submitted by Christopher Phillips
PLEASE NOTE: This blog provides general information on Medicare coverage of hospital and nursing home services, from the perspective of a hypothetical patient.
Should you have additional questions regarding your specific coverage, please feel free to contact the Center for Elder Law & Justice at (716) 853-3087, or our Legal Advice Helpline at 1 (844) 481-0973.
Polly Patient is a 65-year-old woman who was recently hospitalized. Polly spent 4 days and 3 nights in her local hospital, receiving treatment from the hospital physician, Dr. Donna and other hospital staff. Polly has recovered, and is now getting ready to be discharged. Before leaving the hospital, Polly has telephoned her local legal services agency, asking (1) whether or not her hospital stay and (2) whether certain services such as nursing home care, home healthcare, and physical therapy during her recovery will be covered by Medicare.
Common Medicare Questions
Question 1: Will Polly’s Hospital Stay be Covered by Medicare?
Answer: The answer to this question depends on how Dr. Donna classified Polly’s hospital stay from the beginning.
- Scenario 1: Dr. Donna classifies Polly as an “inpatient.” Here, Polly’s hospital stay will be covered by Medicare (Part A, specifically).
- Scenario 2: Dr. Donna classifies Polly as “observation status.” Here, Polly’s hospital stay will not be covered by Medicare Part A. Polly’s stay will likely be covered by Medicare Part B, opening up Polly to hospital co-pays.
Takeaway: Medicare Part A only covers hospital stays where the patient’s stay is classified as an inpatient stay, rather than observation status.
Question 2: How does Dr. Donna classify Polly’s stay as inpatient or observation status?
Answer: Dr. Donna relies on a complex set of medical factors. However, where Dr. Donna expects Polly to need in-hospital care for more than “two midnights,” Dr. Donna should classify Polly’s stay as inpatient.
Takeaway: The “two midnight” approach is only a recommendation. Physicians like Dr. Donna are not required to follow this approach as a rule.
- Coverage Note: It is possible for Polly to stay in the hospital for more than “two midnights,” such as in the scenario above and still not get coverage. Even though Polly’s stay was 4 days and 3 nights, Polly’s stay will not be covered if Dr. Donna only classified her stay as “observation status.”
Question 3: Dr. Donna classifies Polly’s stay as “observation status.” Can Polly Challenge Dr. Donna’s classification?
Answer: No. The decision of whether to classify a patient as observation or inpatient status lies solely with Dr. Donna.
Takeaway: Polly’s only recourse is to try and convince Dr. Donna to change the classification of Polly’s stay to inpatient. One approach recommended by the Center for Medicare Advocacy (CMA) is for Polly to contact her community doctor for a second opinion.
- For more tips on how to speak with a hospital physician about a hospital stay’s classification, visit CMA’s Self-Help Packet for Medicare “Observation Status”.
Question 4: If Polly no longer needs in-hospital care, will Medicare continue to pay for her stay?
Answer: No. Once Dr. Donna determines that Polly no longer needs in-hospital care, Medicare will not cover her stay.
- This includes a scenario where Dr. Donna determines that Polly can be safely discharged to a nursing home. In that case, Polly must accept the first available nursing home bed, or else risk incurring a private-pay hospital bill.
Takeaway: If Polly refuses to leave the hospital after Dr. Donna determines she can be safely discharged (including Dr. Donna recommending Polly go to a nursing home), Polly will receive a private-pay bill for the hospital services starting right after her refusal.
- Depending on the hospital, the “Private Pay” rate for a hospital bed can be more than $1,000 per day.
Question 5: Dr. Donna has cleared Polly for discharge, but Polly does not agree that she is ready to leave the hospital. Can Polly appeal Dr. Donna’s discharge decision?
Answer: Yes. If Polly believes she is being discharged too soon, she can request a review of Dr. Donna’s decision. The review will be conducted by the hospital’s Quality Improvement Organization (QIO).
Takeaway: A discharge notice can be appealed. Review the discharge notice for the proper procedures.
Question 6: Polly is cleared for discharge, but she needs rehabilitation at a nursing home.
Is the nursing home stay covered by Medicare?
Answer: Yes. Medicare will cover Polly’s hospital stay if two conditions are met:
- Polly’s hospital stay was classified as inpatient; AND
- Polly’s hospital stay was for at least three “midnights.”
Takeaway: In order for Medicare to cover nursing home visits, there must first be a “qualifying hospital stay.” A qualifying hospital stay is one spans at least three midnights (three consecutive inpatient hospital stay days), not including the day of discharge.
- Coverage Note: Medicare covers a maximum of 100 days of nursing home care. Beyond those 100 days, nursing home care will either be paid by a resident’s funds or Medicaid. To inquire about Medicaid eligibility, contact your local Department of Social Services.
*COVID-19 WAIVER: In light of the COVID-19 crisis, CMS has temporarily waived this 3-day inpatient requirement for Medicare coverage of nursing home stays.
Question 7: Polly is cleared for Discharge, but needs nursing care at home. Is her in-home nursing care covered by Medicare?
Answer: Yes. Medicare will cover Polly’s home healthcare if certain conditions are met:
- Donna certifies that the services are medically necessary
- Polly is “homebound” (some inability to leave home without great effort);
- Polly does not need those services every day; and
- The home healthcare provider is Medicare-certified.
Takeaway: Medicare will cover some part-time in-home nursing services under certain circumstances, outlined above.
- For more information on Medicare coverage of home health care, visit the website for the Center for Medicare Advocacy.
- Part A – Medicare Part A covers inpatient hospital stays (usually described as those hospital stays that last more than “two midnights”). All Medicare recipients receive Part A coverage.
- Part B – Medicare Part B generally covers things such as doctor visits, medical equipment, and some limited prescription drugs. Most Medicare recipients receive Part B coverage. Look at your individual plan for policy limitations.
- Part D – Medicare Part D covers prescription drugs. Not all Medicare recipients receive Part D coverage. Visit gov’s Part D Coverage website for more information.
- Skilled Nursing Facility (SNF) – a residential facility where residents receive 24-hour care from trained, licensed nurses and other healthcare professionals.
- Qualifying Hospital Stay – a qualifying hospital stay is a pre-requisite for Medicare coverage of SNF services. A qualifying hospital stay, as described in Question 6 above, is defined as an inpatient hospital stay that lasts longer than three consecutive “midnights.”
- The measure of three “midnights” does not include the day of hospital discharge.
- Homebound – required for Medicare coverage of in-home healthcare services. A finding of “homebound” requires a showing of an inability to leave home or that leaving home requires taxing effort.
For more specific information on the specifics of Medicare coverage, please visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227).
PLEASE NOTE: The content contained in this post is merely informational in nature. It should not be construed as legal or medical advice.