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What Medicare May Not Cover

Let’s say you spent time in a hospital, went to another facility for rehabilitation and recovery and then went home, expecting all finances to be cleared by Medicare. Then, one day, you get an unexpected surprise in the mail: bills you don’t understand. You were covered, right?

Unfortunately, maybe you weren’t. Existing laws can seriously affect the status of your stay in the hospital. Medicare specifically states that individuals who seek treatment and care in a hospital must receive inpatient treatment for at least three consecutive days before being sent anywhere else for care and recovery. During your stay, you must be classified as having inpatient status (and not observation status) for your care to be covered.

If you were not assigned inpatient status, your admission will not be covered by Medicare. Additionally, the costs for other medications, tests, co-payments and procedures may be billed directly to you under observation status. Observation-status seniors may even stay in a hospital for several nights in a ward with inpatients, receiving care, medications and meals. Their care is no different than that of other patients, but their status will affect their insurance coverage.

Observation status once referred to an assessment period of 24 hours. Today, the status is sometimes used for periods longer than three days. Hospitals are responding to Medicare rules and regulations that make it more difficult for them to be reimbursed for inpatients. Medicare tried to fix the problem in August of 2013, permitting physicians to admit senior patients as inpatients, provided that they were likely to be there for at least “two midnights” or longer. Unfortunately, those rule changes have not made much of a difference.

Hospitals may also reclassify patients from inpatient status to outpatient status within a year of their stay. As a result, seniors may receive large, unexpected bills.

If you are under observation status, your time at the hospital will not count toward eligibility for a skilled nursing center. Such a center may decline to admit you if you do not meet the three-day inpatient qualification criteria. Even if your status is changed to inpatient during your stay, hospitals cannot retroactively count observation time toward the three-day requirement.

Be certain to ask for status documentation from the hospital to avoid difficult situations later.
Medicare does not offer coverage for custodial care, dentures, cosmetic surgery, dental care, eye care, acupuncture, hearing exams or hearing aids.

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