Center for Medicare Advocacy

Advancing Access to Medicare and Healthcare

Medicare Coverage for Inpatient Hospital Care

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Table Of Contents
  1. What Care Settings Constitute "Inpatient Hospital Care"?
  2. What Sorts of Care are Covered?
  3. Quick Guide to Medicare Coverage and Appeals
  4. Articles and Updates

What Care Settings Constitute “Inpatient Hospital Care”?

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.)

What Sorts of Care are Covered?

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 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.

Quick Guide to Medicare Coverage and Appeals

Medicare Claims for Inpatient Hospital Care are Suitable for Medicare Coverage and Appeal if They Meet the Following Criteria:

The required care is medically necessary, and the patient’s condition is such that the care can only be provided as an inpatient in a hospital, and:

  1. A physician certifies that the services are medically necessary and are required to be provided on an inpatient hospital basis for the individual’s medical treatment, or that inpatient diagnostic study is medically required.
  2. Or inpatient hospital care was initially necessary, and now the individual can only be discharged from the hospital to a skilled nursing facility (SNF), and an appropriate Medicare-certified SNF bed is not available. (Note: A SNF level-of-care means that the patient requires daily skilled services – for example, from skilled therapists and/or nurses)

ADVOCACY TIPS:

  1. The opinion of the patient’s attending physician/provider is key to obtaining a successful Medicare decision. Ask the physicians, and/or other relevant providers, to state in writing, in as much detail as possible, why the coverage standards described above are met in this patient’s case, and submit their statements with all appeals. (Keep copies of all such documents and relevant notices.)
  • A Medicare denial usually does not mean the patient must leave the hospital but does mean further stay will be at the patient’s expense – unless it is successfully appealed.
  • Once notified that Medicare coverage will end, the patient is entitled to an “expedited” review of the determination. If an expedited review is requested immediately, the patient may gain additional time in the hospital before a final decision is issued and charges accrue. If the coverage is denied, the Medicare denial notice provided by the hospital will inform the patient how to immediately appeal by calling the “Beneficiary and Family Centered Care-Quality Improvement Organization” (BFCC-QIO).

Locate the BFCC-QIO for the patient’s geographic region online at Medicare.gov.

The BFCC-QIO for Connecticut is Acentra. Available at (888) 319-8452 Mon-Fri 9am-5pm, weekends and holidays 10am-4pm.

ACTION STEPS:

  1. Ask for a written copy of the hospital discharge plan. Hospitals are required to create a discharge plan to ensure that patients do not suffer adverse health consequences upon discharge. The discharge plan should include pre-discharge counseling and education for the patient and caregivers. It should also include a list of the available Medicare-covered skilled nursing facilities and home health agencies in the patient’s community.
  • Object to the discharge plan if it is inappropriate. Object if the discharge plan is unsatisfactory, either because the individual will be discharged from the hospital too soon, or to a non-certified SNF bed, or to a skilled nursing facility that is too far away from the patient’s community, or sent home when a SNF-level care is actually required.
  • Watch for a receipt of a written notice called an Important Message from Medicare (IM).

The hospital is required to provide an IM within two days of the patient being admitted and no later than four hours before the individual is discharged. This document will include the telephone number for the Beneficiary Family –Centered Care Quality Improvement Organization (BFCC-QIO). To contest the discharge, call the telephone number provided no later than midnight on the day of discharge and state your objection to the discharge, being as specific as possible why it is not appropriate. (Note: Individuals are not financially responsible for the continued hospital stay until noon of the calendar day after receipt of the BFCC-QIO’s appealdecision.

  • Request a Reconsideration

If the BFCC-QIO denies the appeal and agrees that discharge is appropriate, you can file an appeal with a Qualified Independent Contractor (QIC). The appeal must be initiated by noon of the day following the BFCC-QIO’s denial. A decision will be made within 72 hours. While a patient cannot be billed while the QIC’s decision is pending, an unfavorable decision will result in financial liability for the time spent at the hospital waiting for the QIC’s decision.

  • Request an Administrative Law Judge (ALJ) hearing and ask the hospital to bill Medicare for uncovered days. The QIC must issue a written copy of its decision with information on how to request the next level of appeal, an Administrative Law Judge (ALJ) hearing. The ALJ request must be submitted within 60 days. Unfortunately, ALJ hearings and decisions often take a long time to complete. ALJs have 90 days from receipt of the request for hearing to render a decision. To get a hearing and decision as quickly as possible, write “BENEFICIARY APPELLANT” in bold on the request and envelope. Most beneficiaries cannot afford to wait for an ALJ hearing while waiting in the hospital.

Note: Typically, beneficiaries who remain in the hospital after a Medicare denial are discharged before an ALJ hearing is scheduled. If this is the case, ask the hospital to submit a claim to Medicare for all uncovered days through the day of discharge. If that claim is denied, the beneficiary can pursue an appeal through the standard Medicare appeals process.

Beneficiaries who are discharged from the hospital prior to an ALJ hearing can request that the hospital bill Medicare for any uncovered days, regardless of whether the discharge contested is with a BFCC-QIO or QIC. Medicare will determine whether coverage was appropriate and issue a Medicare Summary Notice (MSN) with appeal steps.

Articles and Updates

For older articles, please see our historical archive.