A Medicare Technicality Can Cost Seniors

To compound the pain and suffering seniors endure during a hospitalization, financial heartache could make things worse especially for those who may need skilled nursing care after being discharged from the hospital. In order for Medicare A to potentially pay for up to 100 days of skilled nursing care, the beneficiary must be “admitted to” and spend at least three days in an acute-care hospital. A second condition is that upon discharge they require skilled nursing services such as physical therapy, IV antibiotics, or wound care. However, some Medicare beneficiaries are finding out that Medicare will not cover their post-acute skilled nursing stays because they technically did not have the necessary three-day stay in the hospital despite being there three days or even longer!

How’s that possible, you ask? This is where the technicality plays a role. The reason is that they were kept in the hospital for “observation” rather than actually being admitted as an inpatient. The observation period is meant to be used for testing and performing diagnostics to determine what the illness or injury is and whether full hospitalization is necessary. However, that observation can go for several days and not count towards the required three-day stay. Some of these patients are then transferred to nursing facilities for further care or rehabilitation without any insurance coverage. In some cases with communication breakdown, the individual may not find out they have to pay out-of-pocket until they recieve the bill from the nursing facility a month later. This all leads back to what they thought was a qualifying stay in the hospital. At a range of nearly $200 to $300 a day for skilled nursing care, that Medicare technicality becomes a very costly surprise.

Senator John Kerry (Conn.) and Representative Joe Courtney (Mass.) recently introduced the Improving Access to Medicare Coverage Act S. 818 in the U.S. Senate and H.R. 1543 in the U.S. House of Representatives to help resolve this issue. The bill would not change the three-day stay requirement, but rather it would stipulate that Medicare beneficiaries hospitalized for “observation” for more than 24 hours would be deemed to have been an inpatient, thus making that 24-hour period count as an admission day toward the necessary three-day stay.

This issue affects many seniors as well as younger Medicare beneficiaries who need skilled nursing care. They run the risk of substantial out-of-pocket costs for post-acute care. Worse yet they may settle on going back home despite the physician’s recommendation or could be admitted to a lesser level of care that could jeopardize their health or safety, simply because they don’t want to pay out-of-pocket for a nursing facility.

To learn more about this issue and the legislation trying to change it, go to leadingage.org. If you have questions about Medicare A coverage and eligibility for skilled nursing coverage, please contact the Lifeways Coaching Office at 717.591.7225 or email coach@messiahlifeways.org.

Matthew J. Gallardo

Matthew J. Gallardo

Matt is the Director of Community Engagement and Coaching at Messiah Lifeways. He brings nearly 20 years of experience in counseling, advocating, and guiding older adults and caregivers through many of life’s tough decisions. His diverse background of working in hospital and rehabilitation settings, community services, and senior housing gives him the breadth and depth of knowledge to provide unique solutions, opportunities, and help individuals proactively plan for the future. He serves as the Lifeways Coach and as a writer, blogger, podcaster, and speaker for Messiah Lifeways, located in Mechanicsburg, PA.

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