Source: https://www.medicareadvocacy.org/old-site/InfoByTopic/DischargePlanning/DischargePlanningMain.htm
Timestamp: 2019-04-24 02:09:20+00:00

Document:
Question treating physicians, nurses, social workers, home health care providers, and other care providers about necessary services as the beneficiary’s condition either improves, remains the same, or requires more services. If the beneficiary has opinions and concerns about care, voice them and participate fully in all care decisions.
Become familiar with Medicare guidelines about eligibility for hospital and home and community based care, including nursing facility services and home health services available under the Medicare and Medicaid programs. It is also important to explore other options for services that may be available through other state-based sources of coverage for home and community-based services (HCBS).
Identify and become familiar with available health care services such as visiting nursing services, home health agencies, nursing homes, respite care, friendly visiting services, and religious and civic groups that provide services. An important source of information about services is the Elder Care Locator 1-800-677-1116. In addition, contact the Medicare program’s information line B 1-800-MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048 for the hearing impaired).
Become familiar with discharge planning and its interplay with "transitions," an activity that includes the preparing for and moving from one care setting to another. See "Breathing Life Into Discharge Planning" by Alfred J. Chiplin, Jr.
Use physicians and suppliers who are Medicare-participating providers and, as such, have agreed to accept the Medicare reasonable charge amount, less the 20% beneficiary co-payment, as payment in full for Medicare-covered physician and supplier services (See, 42 U.S.C §§1395u(b)(3);1395n; 42 C.F.R.§§ 410.152(amounts of payment); 424.55(b)(payment to suppliers); 414.48 (limiting charge for non-participating suppliers); see also, 400.402(definitions specific to Medicare, including payment on an assignment related basis) .
Beware of using physicians who have opted out of Medicare and the impact of using such physicians and consequent impact on access to Medicare coverage for the services. See, 42 C.F.R. §§405.400 et seq.
Contact your local Medicare office or the Social Security office for a list of Medicare participating providers and suppliers in your area.
Medicare beneficiaries and their advocates who question the appropriateness of a proposed discharge from a Medicare hospital, whether the discharge is too soon or whether necessary post-hospital services have been arranged, should contact the local Quality Improvement Organization (QIO) and file a complaint. The beneficiary’s hospital discharge notice should provide the name, address, and phone number of the QIO serving your hospital, along with instructions on how to file a complaint (See 42 C.F.R. §§412.42-412.48).
If a beneficiary needs help in filing a complaint with the QIO, contact the Elder Care Locator for information about community-based Medicare assistance, including legal assistance providers funded under the Older Americans Act, the Legal Services Corporation, or private attorney services, or through your network of Health Insurance Counseling Program (HICAP)[sometimes called State Health Insurance Counseling Programs (SHIPs) or Insurance Counseling Assistance (ICAs).]. (Use the eldercare locator number listed above for information about the location of HICAPs/SHIPs/ICAs in your area.). Moreover, QIOs have an obligation to assist Medicare beneficiaries in completing and filing a written complaint.
Effective July 1, 2007, Medicare participating hospitals must deliver valid, written notice, using the "Important Message from Medicare" (IM). This notice is to explain a patient’s rights as a hospital patient including discharge appeal rights. It is to be given at or near admission, but no longer than 2 calendar days following the beneficiary’s admission to the hospital. 42 CFR 405.1205(Traditional Medicare) and 42 CFR §422.620 (Medicare Advantage).
A follow-up copy of the signed IM is given again as far as possible in advance of discharge, but no more than 2 calendar days prior to discharge. 42 CFR §405.1205(c)(1); 42 CFR §422.620(c)(1). Follow-up notice is not required if the provision of the admission IM falls within 2 calendar days of discharge. 42 CFR 405.1205(c)(2)(Traditional Medicare) and 42 CFR 422.620(c)(2) (Medicare Advantage). The exception to the two-notice requirement is an individual who is in the hospital for just 3 days. One IM can be given on day 2, and suffice as both the initial and discharge IM.
The patient becomes financially responsible for the services provided beyond the second day following the date of the notice. 42 C.F.,R. §412.42(c)(3)(ii). See also 42 C.F.R. §§422.620, 489.27 (Beneficiary Notice of Discharge Rights – Medicare Advantage (MA) plans).
For a hospital stay, a beneficiary must request expedited review, orally or in writing, by noon of the first working day after he or she receives written notice that the hospital has determined that the hospital stay is no longer necessary. 42 CFR §405.1206(d)(1); 42 CFR §422.622(d)(1).
The beneficiary (or his or her authorized representative), when requested by the QIO, must be prepared to discuss the case with the QIO. 42 CFR §405.1206(d)(2); 42 CFR §422.622(d).
When the beneficiary requests an expedited determination in accordance with §405.1206(d)(1), the QIO must make a determination and notify the beneficiary, the hospital, and physician of its determination by close of business of the first working day after it receives all requested pertinent information. 42 CFR §405.1206(e)(5); 42 CFR§422.622(e)(5).
Beneficiaries retain the right to utilize the standard appeals (42 U.S.C §1320c-3(a)(14); 42 C.F.R. 466.70 et seq.) process rather than the expedited process in all situations. A QIO may review an appeal from a beneficiary’s request that is not timely filed, but the QIO does not have to adhere to the time frame for issuing a decision, and the limitation on liability does not apply.
The new notice, An Important Message from Medicare about Your Rights (IM), can be found on the CMS website at http://www.cms.gov/BNI/12_HospitalDischargeAppealNotices.asp#TopOfPage (site visited October 3, 2008). The requirements for the new notice are discussed in Guidelines which were released by the Centers for Medicare & Medicaid Services (CMS) on May 25, 2007. In the Guidance, CMS explains when and how Medicare patients must be given information about their discharge and appeal rights. See, http://www.cms.gov/Transmittals/downloads/R1257CP.pdf.
Upon receipt of a hospital’s discharge decision, beneficiaries may appeal the decision by requesting a timely review by the appropriate Quality Improvement Organization (QIO). When QIO review is requested, an additional notice called the Detailed Notice of Discharge (Detailed Notice) is to be given. CMS has issued a Question & Answer document elaborating on the use of IM and the Detailed Notice. See, http://www.cms.gov/BNI/Downloads/CMS-4105-FINAL%20RULE%20Qs%20and%20As%2004%2003%2007.pdf.
Weichardt v. Thompson, Civil Action No. C 03 5490 (N.C.Cal. 2003), was filed in federal district court in San Francisco on behalf of three Medicare beneficiaries who were forced to leave their hospitals before they were medically ready. Each plaintiff (or a family representative) objected to being discharged, but received no written notice of the appeal process for challenging the discharge decision. Neither was told that if they stayed on in the hospital, they would be personally liable for the cost of care. The plaintiffs sought a requirement that Medicare beneficiaries are given timely written notice of the reasons for their discharge and of the procedures for appealing a discharge decision.
As a result of settlement discussions, proposed regulations were published on April 5, 2006, at 71 Fed. Reg. 17052. See, http://edocket.access.gpo.gov/2006/pdf/06-3280.pdf. The proposed regulations required that a Generic Notice of Hospital Non-coverage be given to all Medicare hospital patients at least one day before a planned discharge. This generic notice would specify the date of discharge and explain the procedure for the patient to obtain an expedited review of the medical necessity for continued inpatient care. If the patient indicates that she wishes to appeal, the proposed regulations require that a detailed follow-up notice with specifics about the medical reasons for individual’s discharge be given to her by noon of the next day.
When nursing facility care needs arise, it is important to contact the local Medicare office or the Social Security office for a list of Medicare participating providers and suppliers, or check www.Medicare.gov/NHCompare.
(See, Long-Term Care and Resident Assessment Surveys. State Operations Manual Transmittal No. 8, May 1, 1999, Medicare and Medicaid: SNF Surveys, F283, F284; CMS Pub. 100-07, Appendix PP, Guidance to Surveyors for Long-Term Care Facilities).
The Nursing Home Reform Law prohibits certain discriminatory admissions practices (e.g., waiving rights to Medicare, requiring written or oral assurance that the individual is not eligible for and will not apply for Medicare or Medicaid, requiring third-party guarantee of payment) and requires that facilities display prominently in the facility information about how to apply for and use Medicare benefits. (42 U.S.C. '1395i-3(c)(5)(A); 42 C.F.R. 483. 12(d)(1), (2)).
Note: The PPS RUG-III system does not change Medicare skilled nursing facility (SNF) criteria for admission or services. In addition, the failure to be placed in a high RUGs category does not automatically mean that the beneficiary would be denied SNF coverage under Medicare. (See Pub. L. No. 105-33 (Aug. 5, 1997) §4432(a), amending §1888 of the Social Security Act, by adding subsection (e), 42 U.S.C. §1395yy, effective on or after July 1, 1998. See also, 42 C.F.R.'413.330 et seq.).
If the nursing facilities determines that a patient no longer qualifies for Medicare covered skilled nursing services and wishes to transfer the patient to a non-Medicare certified bed, it must give the beneficiary a transfer notice, explaining appeal rights and the steps to take to exercise the right of appeal (42 C.F.R. §483.12(a)).
The Medicare law does not provide for holding beds as does Medicaid. Under Medicaid, however, when a nursing facility transfers a resident to a hospital or allows a resident to go on therapeutic leave, the nursing facility must provide written information to the resident and a family member or legal representative that specifies the facility’s bed-hold policies. The policies must be consistent with the provisions of the state Medicaid plan regarding bed-hold (42 U.S.C. §1396r(c)(2)(D); (42 C.F.R. §483.12(b)). The Medicare law does not guarantee readmission rights for a Medicare beneficiary who is hospitalized. There is, however, a right of readmission under Medicaid law for Medicaid beneficiaries who’s hospitalization or therapeutic leave exceeds the period paid by the state for bed-hold if the Medicaid beneficiary requires the facility’s services. The right of readmission is an immediate right to the first available bed in a semi-private room (42 U.S.C. §1396r(c)(2)(D)).
The revised notice, also referred to as R1025CP, encompasses broader notice requirements, codified in the Medicare Conditions of Participation (COP). See, www.cms.gov/transmittals/downloads/r1025cp.pdf.
The right to be fully informed orally and in writing (in advance of coming under the care of the agency) of any changes in the charges for items or services to be provided, as well as to be fully informed of the beneficiary’s rights and entitlements under Medicare. 42 U.S.C. §1395bbb (a)(1)(A), 42 C.F.R. §484.10(c)(1) and (2).
Medicare beneficiaries are entitled to an explanation of the circumstances in which a beneficiary has the right to have a "demand bill" submitted. (CMS online manual system, Pub. 100-4, Medicare Claims Processing, www.cms.gov/manuals, Chapter 30, §50).
The beneficiary must file for expedited appeal with a QIO by noon of the day of receipt of notice from the provider.
Advocates should work with physicians and advocacy groups to assure that detailed orders for home health care services are prepared; that physicians fully understand that physician-ordered services are not to be terminated by home health agencies without the consent of the treating physician.
To the extent possible, advocates should provide physicians and home health agencies with information about Medicare coverage that support coverage when coverage issues may be questioned and before a notice of non-coverage is submitted.
Advocates should encourage patients to use the demand bill process where feasible. They should keep in mind that the issue of paying for services pending an appeal will be difficult for many beneficiaries.
Discharge planning process that takes into account the prospect that a patient’s condition might stabilize or otherwise change such that the patient cannot continue to be certifies as terminally ill.
Discharge planning process must include planning for any necessary family counseling, patient education, or other services before the patient is discharge because he or she is no longer terminally ill. 42 C.F.R. §418.26(d).
CMS has developed the following tools that beneficiaries and their caregivers may find useful as they prepare to care for family members or friends at home: www.medicare.gov/caregivers (general information for caregivers looking for information and assistance in caring for another at home) and http://www.medicare.gov/caregivers/index.asp#videos (two short videos – one describing CMS’ discharge planning brochure and the other exploring the need to think through transitions from a hospital or nursing facility to home).

References: §422
 §405
 §422
 §412
 §405
 §422
 §405
 §422
 §405
 §405
 §1320
 v. 
 §4432
 §1888
 §1395
 §483
 §1396
 §483
 §1396
 §1395
 §484
 §50
 §418