Long Term Care Hospitals (LTCHs) play a crucial role in providing specialized care to patients with complex medical conditions. These facilities cater to patients who require an extended period of hospital-level care due to conditions such as Traumatic Brain Injury, prolonged mechanical ventilation, paralysis, significant wound care, and organ failure.
To qualify for Medicare payment as a Long-Term Care Hospital, a facility must meet Medicare’s conditions of participation for acute care hospitals and have an average length of stay greater than 25 days for its Medicare patients. Medicare is a major payer for most LTCHs, covering about two-thirds of LTCH discharges.
When is Medicare Coverage Available in the LTCH?
Medicare coverage for Long-Term Care Hospital care is available if the following criteria are met:
- The patient’s physician ordered an inpatient hospitalization for the treatment of the patient’s condition.
- The hospital, or a unit within the hospital, meets Medicare guidelines to qualify as a Long-Term Care Hospital.
- The individual requires treatment for a medically complex condition that can only be provided in a hospital setting. Additionally, the patient requires a longer length-of-stay for treatment, usually greater than 25 days. The Long-Term Care Hospital must provide comprehensive rehabilitation, respiratory therapy, and pain or wound management, among other necessary programs of care.
It’s important to note that Long-Term Care Hospital 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.
Additional Advocacy Tips
To increase the chances of success when appealing for Medicare coverage, consider the following tips:
- Close medical supervision: A patient requiring close medical supervision, such as 24-hour availability of a physician, may benefit from it being highlighted in the appeal.
- Physician’s support: The opinion and active support of the patient’s attending physician are crucial in obtaining coverage. Request the physician to write a detailed statement explaining why the LTCH care was medically necessary and why the needed care was not available in a skilled nursing facility or other level of care.
- ICU stay not always necessary: While many patients enter Long-Term Care Hospitals from Intensive Care Units (ICUs) or other acute care settings, this is not always the case and is not a requirement for Medicare coverage. However, starting from October 1, 2015, LTCHs will receive reduced payments for patients who have not had an ICU stay prior to admission.
- Timely appeal: Appeal as quickly as possible. In most cases, the patient is entitled to an “Expedited Review,” allowing for additional time in the LTCH before charges accrue, if the patient requests a review immediately.
- How to appeal: The Medicare denial notice provided by the LTCH will contain information on how to immediately appeal by contacting the Beneficiary Family Care-Centered Quality Improvement Organization.
Remember, it’s crucial not to settle for an unreasonably limited Medicare coverage determination and to advocate for the medically necessary care that patients deserve.
FAQs
Q: How long can a Medicare beneficiary stay in a Long-Term Care Hospital?
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 required for Medicare coverage in a Long-Term Care Hospital?
A: While many LTCH patients come from ICUs or acute care settings, an ICU stay is not always necessary for Medicare coverage.
Conclusion
Long Term Care Hospitals play a vital role in providing specialized care for patients with medically complex conditions. By understanding the criteria for Medicare coverage and advocating for the patient’s needs, individuals can ensure they receive the necessary care and support. Stay informed and empowered to make the best decisions for your healthcare journey.
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