One of the brutal truths of Medicare policy: Patients can be hospitalized for days, can undergo exams and tests, can receive drugs — without ever officially being admitted to the hospital. Instead, they’re “under observation,” which means they’re outpatients, not inpatients. And that can bring financial hardships — including lack of coverage for subsequent nursing home care.
Here’s the problem: Medicare Part A covers hospital care for inpatients. Outpatients, including those on observation status, are covered under Part B. That distinction has generated complaints and controversy for years, as the number of inpatient hospitalizations has declined among Medicare recipients and outpatient stays have become more common.
Why does this matter? Because outpatients can face higher payments for drugs and coinsurance, but the big-ticket item is nursing home care. After a hospital discharge, Medicare pays the full cost of skilled nursing for the first 20 days, and most costs up to 100 days — but only for patients who’ve spent three consecutive days as inpatients. Without three inpatient days, patients are on their own. Though most observation patients return home and needn’t to worry about nursing home costs, nearly two-thirds of those who do need skilled nursing have to shoulder the substantial costs themselves, according to a report from the AARP Public Policy Institute.
Patients can appeal just about any other claim that Medicare denies. But there’s no way to appeal observation status.
Recognizing the problem, Congress passed legislation that took effect earlier this year, requiring that hospitals inform patients when they’re not inpatients but are under observation.
Rep. Joe Courtney, Democrat of Connecticut, has introduced a bill in each Congress since 2010, that calls for counting any consecutive three days spent in a hospital toward the requirement for nursing home benefits, regardless of whether people are inpatients or outpatients. the bill drawn broad bipartisan support in both the House and Senate, a raft of medical and advocacy groups also have also endorsed it, including the American Medical Association and AARP. So far, though, the legislation has gone nowhere. For now, suing Medicare for the right to appeal probably offers the best route to fairer treatment for hospitalized patients.
Just be aware of your status; if you go into the hospital, make sure you are admitted and not just, “under observation.”
This article was distilled from here: The New York Times