WHAT HOSPITAL BENEFITS AM I ENTITLED TO
What is a Benefit Period? What happens if the hospital tells me I can no longer receive Medicare coverage? Will I have to leave the hospital immediatel?
How many days of hospital coverage am I entitled to in a benefit period? What can I do if the hospital tries to discharge me prematurely?
Do I pay any deductibles or coinsurance charges during my hospitalization? If my Medicare coverage stops, can I appeal?
How do I qualify for Medicare in-patient hospital coverage? Do I have further appeal rights if my benefits are denied after my first appeal?
Will all services that I receive in the hospital be covered? When should I request a hearing?
Does Medicare Cover specialized facilities? When should I have legal representation?
Does Medicare ever deny coverage of hospital stays? Do I have further appeal rights beyond the hearing?



What is a Benefit Period?
A benefit period starts when you enter the hospital and begin receiving a Medicare covered level of care. It ends 60 days after you stop receiving such care. If, after 60 consecutive days you again begin receiving a Medicare covered level of hospital care, a new benefit period begins. You have an unlimited number of benefit periods.


How many days of hospital
coverage am I entitled to in a
benefit period?
Medicare will cover up to 90 days of inpatient hospital care. Most hospital stays for Medicare patients are much shorter than 90 days. However, if you need hospital care for more than 90 days, you may draw on 60 extra reserve days. These "lifetime reserve days" are not renewable.


Do I pay any deductibles or
coinsurance charges during
my hospitalization?
During 1995, you must pay a deductible of $716.00 per benefit period. There are no coinsurance charges for days I - 60. For the 61st through the 90th day in a benefit period, your coinsurance is 1/4 of the deductible for all covered services. The coinsurance for 1995 is $179.00 per day.

The coinsurance for any lifetime reserve days taken after the 90th day of coverage is 1/2 of the deductible for all covered services. In 1995 the coinsurance for reserve days is $358.00 per day. These amounts change annually.


How do I qualify for Medicare
in-patient hospital coverage?
In order for Medicare to pay for your care, the following conditions must be met:

The hospital participates in the Medicare program and agrees to accept you as a Medicare patient.

You require acute care, i.e., care that can only be provided in a hospital.

A doctor prescribes your treatment.

You may also receive Medicare coverage immediately after receiving acute care services if' you receive skilled nursing care white awaiting placement in a Skilled Nursing Facility, or "SNF.


Will all services that I receive in the hospital be covered?
Medicare will cover all hospital services except private duty nursing, a private room (unless medically necessary) or convenience items such as a telephone or television.


Your Rights to Hospital Benefits...


Does Medicare cover
specialized facilities?
Medicare will cover specialized facilities such as rehabilitation hospitals and care in a psychiatric hospital subject to a lifetime limit of 190 days. Psychiatric care received in a general hospital does not count towards this 190 day limitation.)


Does Medicare ever deny
coverage of hospital stays?
Yes. Each hospital has a "Utilization Review Committee (URC)" which assesses your condition to make sure you are receiving a level of care that Medicare covers. If you are not eligible, the URC will notify you.


What happens if the hospital
tells me I can no longer receive
Medicare coverage? Will I
have to leave the hospital
immediately?
If you are no longer eligible, the Utilization Review Committee will issue a Notice of Non-Coverage (NNC) explaining that your Medicare coverage will stop on the third calendar day after you receive the notice. The notice, however, should not tell you that you have to leave the hospital.


What can I do if the
hospital tries to discharge
me prematurely?
Massachusetts law protects Medicare beneficiaries from premature discharges.

If you think the hospital is trying to discharge you prematurely, you should:

Call the Department of public Health (DPII) Advocacy Office if you think you are being prematurely discharged from the hospital.

Call DPH if you do not receive a written discharge plan or if you receive a discharge plan with which you do not agree. The telephone number for DPH is: 1-800-462-5540.


If my Medicare coverage
stops, can I appeal?
Yes. The Notice of Non Coverage explains how to appeal the Review Committee's decision. This appeal, referred to as a Review, will be conducted by the Massachusetts Peer Review Organization (MassPRO). MassPRO is funded by the federal government and is staffed by health professionals who independently review the care Medicare beneficiaries receive.

To begin the appeal process:

Telephone the MassPRO by noon of the next working day after receiving the notice, so that you will not be financially liable for any covered hospital charges until the MassPRO informs you in writing of its Review decision. MassPRO usually acts within a day or so.

Follow up your telephone call with a letter. Keep a copy of your letter.

You can request a MassPRO Review later than noon of the next working day after receiving the NNC, but YOU will not be protected from financial liability.


Do I have further appeal
rights if my benefits are
denied after my first
appeal?
Yes. If you are not satisfied with the MASSPRO Review, you may appeal again, although you may be financially responsible for any additional stay beginning the day the Review is issued. This next stage of the appeals process, a Reconsideration, is examined in the Review notice from the MassPRO.You may request a Reconsideration up to sixty days after receipt of the MassPRO's Review.

The MassPRO usually conducts a Reconsideration immediately. However, you are not protected from financial liability while awaiting the Reconsideration results.


When should I request a
hearing?
If you are liable for more than $200.00, you may request a hearing before an Administrative Law Judge (ALJ) of the Social Security Administration. You must request this hearing within sixty days of receiving the Reconsideration. The Reconsideration will explain your right to request a hearing.


When should I have legal
representation?
It is very helpful to have legal representation at a hearing before an Administrative Law Judge because Medicare coverage laws are very specific and sometimes confusing. A legal representative will review the circumstances regarding your hospitalization and your medical records to be sure that you received a level of care covered by Medicare.


Do I have further appeal
rights beyond the hearing?
Yes. If you disagree with the ALJ decision, you have sixty days to request a review by an Appeals Council. The Appeals Council, located in Virginia, will decide to either affirm the Administrative Law judge's decision, reverse the decision, or send the case hack to an ALJ to be heard again. After this stage, you may appeal to the United States District Court if the amount in question is $2,000.00 or more.

A self-help brochure published by the
Massachusetts Medicare Advocacy Project (MAP) - July 1995
Reprinted with permission

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