Several years ago, I wrote articles covering two important topics, observation status and using Medicare’s Plan Finder.
What connects these topics today is that in the last few months some very important new information has appeared about each.
For those new to Medicare these may be new topics, so some background information has also been included.
All Medicare beneficiaries need to be aware that your hospital status (whether the hospital considers you an“inpatient” or “outpatient”)affects how much you pay for hospital services like X-rays, drugs and lab tests.
Your hospital status will also affect whether Medicare will cover the costs of rehabilitation or a long-term stay in a skilled nursing facility following your hospital discharge.
If you are discharged from the hospital having been on observation status, it means that you were never formally admitted to the hospital with a doctor’s order. In other words, you were never an inpatient.
Not everyone who spends a day or two in the hospital will be formally admitted.
If you use the services of an emergency department (ED) you will generally be considered to be in this department for “observation.”
Observation services are hospital outpatient services given to help the doctor decide if a patient needs to be admitted as an inpatient or canbe discharged. Observation services may be provided in the ED or another area of the hospital.
An inpatient admission is generally appropriate when you’re expected to need two or more midnights of medically necessary hospital care.
This rule can be interpreted in different ways depending on a number of things.
Such things would include what time of day you are admitted. However, as noted above, a doctor must order such admission and the hospital must formally admit you in order for you to become an inpatient.
So, what does this mean and why is understanding observation status important?
First, Medicare will not pay for either post-hospitalization rehabilitation or nursing home care unless you were officially admitted as an inpatient.
Just because you stay a day or two in the hospital, do not automatically assume that you were officially admitted.
In order to avoid confusion, hospitals now present patients with a hospital-issued Notices of Noncoverage (NINNs) in order to shift the payment responsibility from Medicare to the patient.
This NINN notice can be presented to the patient at the time of entering the hospital or at any time prior to discharge.
Up until recently the only appeal process to this observation decision was handled through the Island Peer Review Organization (IPRO) which is under contract with Medicare to hand appeals.
However, as a recent article in Aging Today reported, another possible channel of recourse has recently been opened for those who are filing appeals.
Last year Judge Michael Shea, of the U.S. District Court of Connecticut, ruled on a class action lawsuit.
Judge Shea found that the class action case, Alexander v. Price, could move forward.
The Judge appointed the Center for Medicare Advocacy, Inc. or CMA (goo.gl/7alyMc), Justice in Aging (goo.gl/WWCRGn) and the law firm of Wilson Sonsini Goodrich & Rosati (goo.gl/TjTzg) to act as class counsel.
Any Medicare beneficiary who received hospital services under observation status since Jan. 1, 2009 may be eligible to participate.
If you feel you may be eligible to become part of this class action, CMA urges you to share your observation stories on their website (goo.fl/7alyMc) and to sign up for their alerts about applying for membership in class.
Remember, this is a lawsuit which may or may not be successful.
However, there are no costs involved to see if you are eligible or to participate as the lawsuit moves forward. CMA believes that the more stories that are reported the better the changes are that the action will succeed.
If there are changes in the status of the lawsuit, we will report on them in future columns.
Study of the Medicare Plan Finder too. Older Americans are told to use the Medicare Plan Finder to compare and choose the Medicare Part D drug plan that best fits their needs.
Unfortunately, according to a new research study by the National Council on Aging and
the Clear Choice Campaign, the Medicare Plan Finder has a number of problems.
The full report is available at https://www.ncoa.org/resources/modernizing-medicare-plan-finder-report.
Among the key findings, the study reports that out-of-pocket cost information is difficult to understand, the website layout and display are confusing and the plan information is not consistently accurate.
Also, provider and pharmacy directories are difficult to navigate.
One of the most often sited deficiencies is that human support is not available through the Medicare Plan Finder.
Fortunately, for all the residents of Oneida County, that essential human support is available through the Oneida County Office for the Aging/Continuing Care/NY Connects Health Insurance Information, Counseling and Assistance program (HIICAP).
The HIICAP provides the much-needed human support missing from Medicare Plan Finder in the form of highly trained counselors who provide their service to Medicare beneficiaries at the following locations in Oneida County:
• Ava Dorfman Senior Citizens Center, 305 E. Locust St., with hours of operation on Tuesday and Thursday from 10 a.m. to 2 p.m.
While consumers are seen on a “first come, first served” basis, you may call the Dorfman Center at 315-337-1648 to see if there are long wait times.
• North Utica Senior Citizens Community Center, 50 Riverside Drive, Utica with hours of operation on Monday, Wednesday and Friday from 10 a.m. to 2 p.m.
Consumers are counseled on a “first come, first served” basis. However, if you want to call ahead to see how busy the office is you may call the Center’s HIICAP program at 315-724-8680.
HIICAP services are provided by Oneida County Office for Aging and Continuing Care/NY Connects.
Anyone with questions about HIICAP, including issues with your Medicare Advantage Plan, should call the program directly at 315-798-5456 and press 4 in the choice list. It will direct you to someone who can assist you.
All HIICAP related services are provided at no cost to Medicare beneficiaries. Remember that, unlike the Medicare Plan Finder website, help is only a phone call away.
EDITOR’S NOTE: Dr. William Lane is the owner of William Lane Associates, a gerontological firm which located in Homer. He writes a monthly column on HIICAP related issues for the OFA. Dr. Lane does not sell insurance, work for any insurance company or recommend any insurance products.