Medicare
A Message from Medicare
Your Rights as a Patient
You have the right to receive necessary hospital services covered by Medicare or covered by your Medicare Health Plan (“your plan”) if you are a plan enrollee.
You have the right to know about any decisions that the hospital, your doctor, your plan, or anyone else makes about your hospital stay and who will pay for it.
Your doctor, your plan, or the Hospital should arrange for services you will need after you leave the hospital. Medicare or your plan may cover some care in your home (home health care) and other kinds of care, if ordered by your doctor or by your plan. You have a right to know about these services, who will pay for them, and where you can get them. If you have any questions, talk to your doctor or plan, or talk to other hospital personnel.
Your Discharge & Medicare Appeal Rights
Date of Discharge: When your doctor or plan determines you can be discharged from the hospital, you will be advised of your planned date of discharge. You may appeal if you think you are being asked to leave the hospital too soon. If you stay in the hospital after your planned date of discharge, it is likely your charges for additional days in the hospital will not be covered by Medicare or your plan.
Your Right to an Immediate Appeal without Financial Risk
When you are advised of your planned date of discharge, if you think you are being asked to leave the hospital too soon, you have the right to appeal to your Quality Improvement Organization (also known as QIO). The QIO is authorized by Medicare to provide a second opinion about your readiness to leave. You may call Medicare toll-free, 24 hours a day, at 1-800-MEDICARE (1-800-633-4227) or TTY/TTD: 1-877-486-2048 for more information on asking your QIO for a second opinion. If you appeal to the QIO by noon of the day after you receive a non-coverage notice, you are not responsible for paying for the days you stay in the hospital during the QIO review, even if the QIO disagrees with you. The QIO will decide within one day after it receives the necessary information.
Other Appeal Rights
If you miss the deadline for filing an immediate appeal, you may still request a review by the QIO (or by your plan, if you are a plan enrollee) before you leave the hospital. However, you will have to pay for the costs of your additional days in the hospital if the QIO or your plan denies your appeal. You may file for this review at the address or telephone number of the QIO or your plan.
Coverage of Prescription Drugs, Outpatients, Observation Patients, & ER Patients
The Medicare program provides limited benefits for outpatient drugs:
- Under Medicare Part A (inpatient), drugs provided during acute inpatient stays or qualified skilled nursing facilities are covered if Medicare requirements are met.
- Under Medicare Part B (outpatient, including outpatient hospital stays), drug coverage is limited to drugs that are not usually self-administered.
Even though hospitals are not required to give prior notice to bill a beneficiary for self-administered drugs provided in the outpatient setting, Carlinville Area Hospital & Clinics has elected to inform you that you may receive a bill for these medications.
During your outpatient treatment, you may be given medication that is considered self-administered by Medicare. Medicare defines self-administered drugs as medications that the patient could, in another setting, take themself 50% of the time. The list of medications includes but is not limited to tablets, capsules, caplets, elixirs, sprays, drops, inhalants, and some injectable drugs.
Medications brought from home in their original pharmacy container, properly labeled and positively identified by pharmacy, may be used with a physician order. If we can use your home medication, you will not receive a bill for these medications.
When coming to the hospital for outpatient admission, to see a physician, receive outpatient services, or use the Emergency Room, always try to bring any medication in its original pharmacy container that you have been taking. To remain compliant with Medicare regulations related to the billing of these drugs, medical providers are required to submit self-administered drugs as non-covered items on our billing to Medicare.
You will receive a bill from the hospital following payment of our claim by Medicare. In addition to any deductible and co-insurance due, this bill will reflect the charges for unpaid self-administered drugs. You will be expected to pay for the non-covered items. With few exceptions, most secondary insurance carriers do not cover self-administered drugs. You may request an itemized statement for billing of the self-administered drugs to a Medicare Part D carrier.
If you have any questions, call our Business Office at 217-854-3141 ext 356. If you would like additional information about your coverage by Medicare, call 1-800-633-4227 or visit Medicare.gov.
Are you a hospital inpatient or outpatient? If you have Medicare, ask!
Did you know even if you stay in the hospital overnight, you might still be considered an outpatient? 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 may also affect whether Medicare will cover care you receive in a skilled nursing facility (SNF). An inpatient admission begins the day you’re formally admitted to the hospital with a doctor’s order. The day before you’re discharged is your last inpatient day. You’re an outpatient if you’re getting emergency department services, observation services, lab tests, or X-rays and the doctor hasn’t written an order to admit you as an inpatient even if you spend the night at the hospital.
If you’re in the hospital more than a few hours, always ask your doctor or the hospital staff if you’re an inpatient or an outpatient.
Understand the differences in Original Medicare coverage for hospital inpatients and outpatients and how these rules apply to some common situations. If you have a Medicare Advantage Plan (like an HMOor PPO), costs and coverage may be different. Check with your plan.
What do I pay as an inpatient?
Medicare Part A (Hospital Insurance) covers inpatient hospital services. Generally, this means you pay a one-time deductible for all your hospital services for the first 60 days you’re in the hospital. Medicare Part B (Medical Insurance) covers most of your doctor services when you’re an inpatient. You pay 20% of the Medicare-approved amount for doctor services after paying the Part B deductible.
What do I pay as an outpatient?
Medicare Part B covers outpatient hospital and doctor services. Generally, this means you pay a co-payment for each individual outpatient hospital service. This amount may vary by service. Note: The co-payment amount for a single outpatient hospital service can’t be more than the inpatient hospital deductible. In some cases, your total co-payment for all services may be more than the inpatient hospital deductible. Part B also covers most of your doctor services when you’re a hospital outpatient. You pay 20% of the Medicare approved amount after the Part B deductible. Generally, the prescription and over-the-counter drugs you get in an outpatient setting like an emergency department (sometimes called self-administered drugs) aren’t covered by Part B.
If you have Medicare Part D prescription drug coverage, these drugs may be covered under certain circumstances. You will likely need to pay out-of-pocket for these drugs and submit a claim to your drug plan for a refund. Call your plan for more information. For more detailed information on how Medicare covers hospital services — including premiums, deductibles, and co-payments — read the “Medicare & You” handbook. You may also call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
Below are some common situations and a description of how Medicare will pay. Remember, you pay deductibles, co-insurance, and co-payments.
| Situation | Inpatient or Outpatient | Part A Pays | Part B Pays |
|---|---|---|---|
| You’re in the emergency department, and then you’re formally admitted to the hospital with a doctor’s order. | Inpatient | Your hospital stay usually including emergency department services | Your doctor services |
| You visit the emergency department for a broken arm, get X-rays and a cast, and go home. | Outpatient | Nothing | Doctor services and hospital outpatient services (for example, emergency department visit, X-rays, casting) |
| You come to the emergency department with chest pain, and the hospital keeps you for 2 nights for observation services. | Outpatient | Nothing | Doctor services and hospital outpatient services (for example, emergency department visit, observation services, lab tests, EKGs) |
| You come to the hospital for outpatient surgery, but they keep you overnight for high blood pressure. Your doctor doesn’t write an order to admit you as an inpatient. You go home the next day. | Outpatient | Nothing | Doctor services and hospital outpatient services |
| Your doctor writes an order for you to be admitted as an inpatient and the hospital later tells you they’re changing your status to outpatient. Your doctor must agree, and the hospital must tell you in writing—while you’re still in the hospital—that your status changed. | Outpatient | Nothing | Doctor services and hospital outpatient services |
Remember, even if you stay overnight in a regular hospital bed, you might be an outpatient. Ask the doctor or hospital.
How would my hospital status affect the way that Medicare covers the care I get in a skilled nursing facility?
Medicare will only cover care you get in a Skilled Nursing Facility (SNF) if you first have a “qualifying hospital stay.” A qualifying hospital stay means you’ve been a hospital inpatient for at least three consecutive nights (counting the day you were admitted as an inpatient, but not counting the day of your discharge). If you don’t have a three-night inpatient hospital stay, ask if you can get care after your discharge in other settings (like home health care) or if any other programs (like Medicaid or veterans’ benefits) can cover your SNF care. Always ask your doctor or hospital staff if Medicare will cover your SNF stay.
How would a hospital’s observation services affect my SNF coverage?
Your doctor may order “observation services” to help decide whether you need to be admitted to the hospital as an inpatient or can be discharged. During the time you’re getting observation services in the hospital, you’re considered an outpatient. This means you can’t count this time towards the three-day inpatient hospital stay needed for Medicare to cover your SNF stay.
Below are some common hospital situations that may affect your SNF coverage.
| Situation | Is Your Stay Covered? |
| You came to the emergency department, were formally admitted to the hospital with a doctor’s order as an inpatient for three days, and you were discharged on the fourth day. | Yes, you met the three-night inpatient stay requirement for a covered SNF stay. |
| You came to the emergency department and spent one day getting observation services. Then, you were an inpatient for two more days. | No. Even though you spent three nights in the hospital, you were considered an outpatient while getting emergency department and observation services. These days don’t count toward the three-day inpatient stay requirement. |
Remember, an inpatient admission begins the day you’re formally admitted to the hospital with a doctor’s order. That date is your first inpatient day. The day you are discharged doesn’t count as an inpatient day.
What are my rights?
No matter what type of Medicare coverage you have, you have certain guaranteed rights. As a person with Medicare, you have the right to all the following:
- Have your questions about Medicare answered
- Learn about all your treatment choices and participate in treatment decisions
- Get a decision about health care payment, services, or prescription drug coverage
- Get a review of (appeal) certain decisions about health care payment, coverage of services, or prescription drug coverage
- File complaints (sometimes called grievances), including complaints about the quality of your care
- For more information about your rights, the different levels of appeals, and Medicare notices, read the booklet “Your Medicare Rights and Protections.” You can also call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
Where can I get more help?
For more information on Part A and Part B coverage, read your “Medicare & You” handbook, or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
For more information about coverage of self-administered drugs, read “How Medicare Covers Self-Administered Drugs Given in Outpatient Settings.”
For questions or to report complaints about the quality of care for a Medicare-covered service, call your Quality Improvement Organization (QIO). Call 1-800-MEDICARE or visit Medicare.gov and select “Find Helpful Numbers and Websites.”