Your Medicare Rights During a Hospital Stay

From California Advocates for Nursing Care Reform.

During a hospital stay, Medicare beneficiaries have important rights to receive the medical care they need. You have these rights whether you are enrolled in the original Medicare plan or a Medicare health plan.

Your Medicare Rights

Medicare certified hospitals must:

    • Identify your anticipated discharge needs within 24 hours of your admission;
    • Provide discharge planning assistance for every patient;
    • Identify discharge goals, your preferences, and services you need and their availability;
    • Assess whether you can get needed care where you had been living;
    • Share a list of nearby home health agencies or nursing homes if their services are indicated;
    • Discuss evaluation results with you;
    • Prepare and share with you a transfer summary that includes the treatment plan and instructions on post-hospital care;
    • Use professional staff to deliver discharge planning services;
    • Ensure that necessary care and services are delivered upon discharge;
    • Prepare you and your family for discharge and your post-hospital care needs through education and counseling;
    • Transfer or refer you, along with necessary medical information, to appropriate facilities, agencies or outpatient services, as needed, for follow–up care.

These requirements are found at Title 42, Code of Federal Regulations, Section 482.43 and Title 42, United States Code, Section 1395x(ee). Additional California hospital discharge planning requirements are established at California Health and Safety Code Sections 1262.5 –1262.6.

At or near admission, a hospital must give you the Important Message from Medicare. This Medicare notice explains that you have the right:

    • To receive Medicare covered services, including necessary hospital services and services you may need after discharge, if ordered by your doctor. You have a right to know about these services, who will pay for them, and where you can get them.
    • To be involved in any decisions about your hospital stay, and know who will pay for it.
    • To appeal if you think you are being discharged too soon. The notice also explains how to file an appeal.

Notifying You of Your Rights

To make sure you are informed about your discharge rights in a timely manner, hospitals must usually give you the Important Message from Medicare twice, once upon admission and again before discharge.

The hospital must first give you the Important Notice from Medicare at or near admission, but no later than two days after admission. At that time it must ask you to sign and date the notice. The hospital must give you the original copy of the signed notice and keep a copy for its records.

Before you are discharged, the hospital must give you another copy of the Important Message from Medicare. It must give you this notice as far in advance of your discharge as possible, but no more than 2 days before your planned date of discharge. The second notice is not required during very short hospital stays if the original notice was given to you within two days of your planned discharge date.

If the hospital gives you the second notice on the date of your discharge, it must deliver it to you at least four hours before your planned discharge.

The hospital must deliver the Important Message from Medicare to you in person. However, if you cannot understand the notice, the hospital must deliver it to your representative and ask him or her to sign it. Your representative can be someone who has legal authority to act for you, a family member or close friend.

Hospitals have a strong financial incentive to discharge Medicare patients as quickly as possible. Medicare generally pays hospitals flat rates based on the type of medical problem being treated. If the hospital spends less money on your care than Medicare pays, it makes money, and vice versa.

To protect you from being discharged too quickly, Medicare gives you the right to appeal hospital discharge decisions. It also requires the hospital to provide any discharge planning services you need.

Appealing Hospital Discharge Decisions

Your hospital, doctor, or Medicare health plan will inform you of your planned date of discharge. If you think you are not ready to leave the hospital, tell your doctor and the hospital staff immediately about your concerns. Ask your doctor to advocate for your interests. Sometimes hospitals and health plans pressure doctors to arrange quick discharges.

You should request an appeal if your concerns about early discharge are not resolved. You can stay in the hospital and Medicare will continue to cover your stay as long as you file the appeal before you are discharged. Once you appeal, you will not have to pay for the services you receive during the appeal (except for charges like copays and deductibles).

It is best to file your appeal on or just before the planned date of discharge. Ask for an “Immediate Review.” Your representative, such as a legal agent or family member, can file an appeal on your behalf.

To file your appeal, call Livanta at 1–877–588-1123. Livanta is a “Quality Improvement Organization” (QIO) – a private organization working under contract with Medicare to handle certain appeals and other matters. Tell Livanta why you object to the planned discharge and provide any information that supports your appeal. For more information about Livanta or appeals, go to the Livanta web site at http://bfccqioarea5.com/states/ca.html

After you file your appeal, the hospital (or your Medicare health plan) must give you a Detailed Notice of Discharge that explains the reasons it thinks you are ready to be discharged. The hospital will send a copy of your medical records to Livanta for its review.

These appeals are completed quickly. Livanta will notify you and the hospital of its decision, usually within one day after it receives the necessary information.

    • If Livanta finds that you are not ready to be discharged, Medicare will continue to cover your hospital stay.
    • If Livanta finds you are ready to be discharged, Medicare will continue to cover your services until noon of the day after Livanta notifies you of its decision.

Livanta must notify you of its decision by telephone and in writing. The written notice will describe additional options for appeal.

Discharge Planning Services

Medicare certified hospitals must help patients arrange care needed after discharge. This service, called discharge planning, is usually provided by the hospital’s social work or discharge planning department.

Contact the discharge planning department as soon as possible after admission. Discuss help and care you will need after discharge. Ask for recommendations and help in arranging necessary care and services. Request a copy of your written discharge plan and seek changes if necessary.

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