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DESCRIPTION OF HOSPITAL BENEFIT
APPEALS PROCESS

RECENT ARTICLES AND UPDATES


The Medicare Hospital Benefit

Inpatient hospital care includes care you get in:

  • Acute care hospitals
  • Critical access hospitals
  • Inpatient rehabilitation facilities
  • Long-term care hospitals
  • Inpatient care as part of a qualifying clinical research study
  • Mental health care (Inpatient mental health care in a psychiatric hospital is limited to 190 days in a lifetime.)

Medicare inpatient hospital care coverage includes:

  • Semi-private rooms
  • Meals
  • General nursing
  • Drugs as part of your inpatient treatment
  • Other hospital services and supplies

Note that Medicare Part B (Medical Insurance) covers your doctors’ services you get while you’re in a hospital.

This doesn’t include:

  • Private-duty nursing
  • Private room (unless medically necessary )
  • Television and phone in your room (if there’s a separate charge for these items)
  • Personal care items, like razors or slipper socks

Your Costs (2020)

  • $1,408 deductible for each benefit period.
  • The Medicare Inpatient Hospital Benefit covers up to 90 days of care, and an additional 60 “lifetime reserve” days, with increasing cost-sharing:
    • Days 1–60: $0 coinsurance for each benefit period.
    • Days 61–90: $352 coinsurance per day of each benefit period.
    • Days 91 and beyond: $704 coinsurance per each “lifetime reserve day” after day 90 for each benefit period (up to 60 days over your lifetime).
  • Beyond lifetime reserve days : all costs.

Your doctor or other health care provider may recommend you get services more often than Medicare covers. Or, they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs. Ask questions so you understand why your doctor is recommending certain services and whether Medicare will pay for them.

The hospital may charge a beneficiary for services received in the hospital only if all of the following conditions have been met:

  • The hospital must determine that the patient no longer requires in-patient hospital care (the phrase “in-patient hospital care” includes cases where a beneficiary needs skilled nursing facility care, but a skilled nursing facility bed is not available.)
  • The attending physician agrees with the hospital determination in writing, or, if the hospital is unable to obtain an agreement from the physician, the QIO concurs in the hospital’s determination.
  • The hospital must notify the beneficiary in writing that the beneficiary no longer requires in-patient hospital care; that customary charges will be made for continued hospital care beyond the second day following the date of the notice; that the QIO will make a formal determination on the validity of the hospital’s finding if the beneficiary remains in the hospital after he or she is liable for charges; that the hospital’s denial decision is appealable, and that any charges for continued care will be refunded if a finding is made on appeal that the patient did require continued in-patient hospital care.

Hospital Discharge and Appeal

If you believe you’re being discharged from a hospital too soon, you have the right to an immediate review of your case. The Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) in your area will conduct the review.

You may be able to stay in the hospital (coinsurance and deductible may apply) while the BFCC-QIO reviews your case. The hospital can’t force you to leave before the BFCC-QIO reaches a decision.

Within 2 days of your admission and prior to your discharge, you should get a notice called “An Important Message from Medicare about Your Rights.” This notice is called the Important Message from Medicare or the IM. If you don’t get this notice, ask for it. This notice lists the BFCC-QIO’s contact information and explains:

  • Your right to get all medically necessary hospital services
  • Your right to be involved in any decisions that the hospital, your doctor, or anyone else makes about your hospital services and to know who will pay for them
  • Your right to get the services you need after you leave the hospital
  • Your right to appeal a discharge decision and the steps for appealing the decision
  • The circumstances under which you will or won’t have to pay for charges for continuing to stay in the hospital
  • Information on your right to get a detailed notice about why your covered services are ending

If the hospital gives you the IM more than 2 days before your discharge day, it must give you a copy of your original, signed IM or provide you with a new one (that you must sign) before you’re discharged.

You may have the right to ask the BFCC-QIO for a fast appeal. Follow the directions on the IM to request a fast appeal if you think your Medicare-covered hospital services are ending too soon. You must ask for a fast appeal no later than the day you’re scheduled to be discharged from the hospital.

If you ask for your appeal within this time frame, you can stay in the hospital while you wait to get the BFCC-QIO’s decision. You won’t have to pay for your stay (except for applicable coinsurance or deductibles).

When the BFCC-QIO gets your request within the fast appeal time frame, it will notify the hospital (and, if you are in a Medicare Advantage plan, the plan). Once the hospital and plan are notified by the BFCC-QIO, you will receive a “Detailed Notice of Discharge” by noon of the day after the BFCC-QIO notifies the hospital. The notice will include:

  • Why your services are no longer reasonable and necessary or are no longer covered
  • A description of the applicable Medicare coverage rule or policy, including information on how you can get a copy of the policy
  • How the applicable coverage rule or policy applies to your specific situation

If you are in a Medicare Advantage plan, you can also ask your plan for copies of any of the materials that your plan sent to the BFCC-QIO about your hospital discharge. The BFCC-QIO will look at your medical information provided by the hospital and will also ask you for your opinion. The BFCC-QIO will decide if you’re ready to be discharged within one day of getting the requested information.

If the BFCC-QIO decides that you’re being discharged too soon:

  • Medicare will continue to cover your hospital stay as long as medically necessary (except for applicable coinsurance or deductibles) if your plan previously authorized coverage of the inpatient admission, or the inpatient admission was for emergency or urgently needed care.
  • You may need to appeal the denial of coverage for your plan to pay if your plan never authorized the inpatient admission, or the inpatient admission wasn’t for emergency or urgently needed care.

If the BFCC-QIO decides that you’re ready to be discharged and you met the deadline for requesting a fast appeal:

  • You won’t be responsible for paying the hospital charges (except for applicable coinsurance or deductibles) incurred through noon of the day after the BFCC-QIO gives you its decision. If you get any inpatient hospital services after noon of that day, you may have to pay for them.

If you leave the hospital or miss the deadline to file an expedited appeal to the QIO:

  • You have 30 days from your original discharge date to request a review. The BFCC-QIO will send a written decision letter once it receives all the information it needs from you and the hospital.
  • If you’re in a Medicare Advantage Plan, you can ask your plan for an appeal, but different rules apply.
  • For standard appeals (requesting a reconsideration of the BFCC-QIO decision and beyond) and Medicare Advantage information, see https://www.medicareadvocacy.org/medicare-info/medicare-coverage-appeals/

Recent Articles and Updates

For older articles, please see our historical archive.