Long Term Care Hospitals (LTCHs) play a vital role in providing specialized care to patients with medically complex conditions. These conditions include Traumatic Brain Injury, prolonged mechanical ventilation, paralysis, significant wound care, and organ failure, among others. LTCHs are designed to offer a hospital-level of care for an extended period, ensuring that patients receive the necessary treatment and support they require.
Medicare Coverage for LTCHs
To qualify for Medicare payment, LTCHs must adhere to Medicare’s conditions of participation for acute care hospitals and have an average length of stay exceeding 25 days for Medicare patients. Medicare is a major payer for most LTCHs, accounting for about two-thirds of LTCH discharges.
When is Coverage Available?
Medicare coverage for Long-Term Care Hospital care is available if the following criteria are met:
- The patient’s physician has ordered inpatient hospitalization for the treatment of their condition.
- The hospital or a unit within the hospital meets Medicare guidelines to qualify as a Long-Term Care Hospital.
- The patient requires treatment for a medically complex condition that can only be provided in a hospital setting. Additionally, the patient requires a length-of-stay typically exceeding 25 days, along with specialized programs of care provided by the LTCH, such as comprehensive rehabilitation, respiratory therapy, and pain or wound management.
Additional Advocacy Tips
Here are some additional tips for advocating and securing Medicare coverage for LTCH care:
- LTCH stays count towards the beneficiary’s Part A inpatient hospital stay allotment per benefit period. Each Medicare beneficiary is eligible for up to 90 days of hospital coverage per benefit period, with an additional “lifetime reserve” of 60 days.
- Close medical supervision, including 24-hour availability of a physician, can strengthen the case for coverage.
- The opinion and active support of the patient’s attending physician are crucial. If the physician believes that LTCH care is medically necessary and unavailable in other care settings, a detailed statement explaining the medical necessity can greatly support the appeal.
- While many patients enter LTCHs from ICUs or acute care settings, this is not always a requirement for Medicare coverage. However, from October 1, 2015, LTCHs receive lower payments for patients without prior ICU stays, which may pose challenges in accessing necessary LTCH care.
- Appeal the Medicare denial as quickly as possible. Patients are usually entitled to an “Expedited Review,” which allows for additional time in the LTCH before charges accrue if an immediate review is requested.
- The LTCH’s Medicare denial notice provides instructions for an immediate appeal by contacting the Beneficiary Family Care-Centered Quality Improvement Organization. It’s essential to pursue the appeal process and not settle for unreasonable coverage limitations.
- Ensure that the patient doesn’t forgo medically necessary care and advocate for the full Medicare coverage they deserve.
FAQs
Q: How long can a Medicare beneficiary stay in an LTCH?
A: Medicare beneficiaries are eligible for up to 90 days of hospital coverage per benefit period, with an additional “lifetime reserve” of 60 days.
Q: Is an ICU stay a requirement for Medicare coverage in an LTCH?
A: While many patients enter LTCHs from ICUs or acute care settings, an ICU stay is not always a requirement for Medicare coverage. However, post-October 1, 2015, LTCHs receive lower payments for patients without an ICU stay prior to admission, which may pose challenges for accessing necessary LTCH care.
Q: How can I appeal a Medicare denial for LTCH coverage?
A: The LTCH’s Medicare denial notice will provide instructions for an immediate appeal by contacting the Beneficiary Family Care-Centered Quality Improvement Organization.
Conclusion
Long Term Care Hospitals (LTCHs) provide essential care for patients with medically complex conditions. By understanding Medicare coverage criteria, advocating for the patient’s needs, and following the appeal process, patients can access the specialized care they require. If you or a loved one needs LTCH care, it’s essential to explore the available options and ensure you receive the coverage and support you deserve.
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