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Medicare Rights, Hospital Stays, and Skilled Nursing Facilities

HICAP

January 18 2021

Are you a Medicare Beneficiary and confused about your Medicare Rights? You have certain rights and protections designed to protect you when you receive health care, to make sure you get the health care services the law says you can get, to protect you against unethical practices, and to protect your privacy. You have the right to receive information in a way you understand from Medicare, health care providers, and contractors. The understanding of your coverage is indicative to making important health care decisions.

Unless waived, most people 65 or older have Medicare Part A (Hospital Insurance). This covers your Inpatient care in hospitals, Inpatient care in a skilled nursing facility (not custodial or long-term care), hospice care, home health care, and inpatient care in a religious non-medical health care institution.

Transfers to Skilled Nursing Facilities after a Hospital stay are common and it is important to understand your coverage and to exercise your rights in doing so. To qualify for skilled nursing facility care coverage, your doctor must certify that you need daily skilled care (like intravenous fluids/medications or physical therapy). You may receive skilled nursing or therapy care coverage if it is necessary to improve or maintain your current condition. Medicare covers semiprivate rooms, meals, skilled nursing and therapy services, and other medically necessary services and supplies in a skilled nursing facility. Medicare only covers these services after a 3-day minimum, medically necessary, inpatient hospital stay for a related illness or injury.

While in a skilled nursing facility, you are required to pay nothing for the first 20 days of each benefit period. A benefit period begins the day you are admitted as an inpatient in a hospital or skilled nursing facility. The benefit period ends when you have not gotten any inpatient hospital care (or skilled nursing facility) for 60 days in a row. There are no limits to the number of benefit periods.

If the facility decides to discharge you based solely on a lack of improvement, and not because you no longer require skilled nursing or therapy care, you can appeal. You have rights when you feel like you are being discharged too soon!

If you are a Medicare Beneficiary and you feel like your rights may have been violated contact Livanta’s Helpline: (877) 588-1123 or TTY: (855) 887-6668. Livanta is a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). BFCC-QIOs are responsible for medical case review, which supports the rights of people on Medicare. Livanta provides Medicare Beneficiaries and their family assistance with appeals of discharge, quality of care concerns, and Beneficiary complaints. Further details regarding Livanta and their assistance can be found at www.lavintaqio.com.

Advocating for your rights can feel overwhelming during a time when you need help the most. Valley Caregiver Resource Center’s Health Insurance and Advocacy Program (HICAP) has registered counselors that are available to assist Medicare Beneficiaries and their families with their concerns over any Medicare Rights being violated. You are not alone and we are here to help. Please contact HICAP at (559) 224-9117 Monday –Friday 8am-5pm.

By- Jennifer Webb HICAP Program Manager

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