Problems With "Observation" Status And Medicare

One of the most frustrating things about trying to help someone get into a nursing home and figure out how to pay for it is Medicare coverage.

To recap, Medicare is the federal insurance program that pays for things like hospitalizations, doctor visits, and prescription drugs for seniors. As opposed to Medicaid, which we primarily discuss on this blog, which is the jointly-funded state/federal program that pays for long-term care admissions for seniors (among many other things).

The basic rule for nursing home planning is that if you are admitted into the hospital for 3 days, Medicare will cover up to your first 100 days if you are discharged to a nursing home. There are a slew of complicated technical rules about how you must be discharged and how you can use those 100 days, but I want to focus on what we think is a very basic prerequisite, the condition that you must be admitted to the hospital for 3 days.

For most of my clients, this used to be simple. You would have a triggering event requiring hospitalization and would spend the minimum 3 days recovering prior to discharge to a nursing home for more recovery. Recent changes in Medicare reimbursements to hospitals have triggered an increase in patients being held for "observation".

Being held for observation rather than being admitted as a patient eliminates the possibility that Medicare will pay for up to the first 100 days if you are discharged to a nursing home. This really hurts patients and their families more than anyone else. If your family member is going to need Medicaid to fund the nursing home stay, this accelerates the requirement to file a Medicaid application.

Rather than encouraging clients to engage in an appeal of the Medicare process, which can be lengthy, expensive and not that rewarding, we suggest strong family advocacy to the hospital personnel and staff if your loved one is being held for observation instead of admitted, especially if you think discharge to a nursing home is a likely outcome.

The real solution, or at least one of them, would be to permit stays in the hospital under observation status to count toward your 3 midnights for Medicare coverage. There are several proposals in Congress to address this, but in the meantime, zealous advocacy on behalf of our clients is the only resolution short of litigation.