Overview of Medicare’s “Pumpkin Rule” taking effect
In 2011, the first of the baby boom generation reached what used to be known as retirement age. And for the next 18 years, boomers will be turning 65 at a rate of about 8,000 a day. As this unique cohort grows older, it will likely transform the institutions of aging — just as it has done to other aspects of American life. Just as we can expect some changes, they can look forward to some as well. While nearing the application age for Medicare, older Americans have a wealth of much-needed research they can expect to cram in before they sign up. Unbeknownst to the ones that haven’t yet started to prepare for this process, Medicare (and all it’s supplements) can come as a whirlwind of need-to-know information that isn’t always easily attained. Furthermore, the updates to Medicare as a whole can be a blistering reading process. This year, among many other changes, one stands out the most to me in relation to our beloved seniors. First off, Medicare has instituted a rule that requires hospitals to designate a patient’s status (observed or admitted) upon seeing a physician when entering the hospital.
The admitted/in observation rule seems to have been a bone of contention with many seniors in past years. In a nutshell, to clarify this confusing situation, a policy popularly known as the “two-midnight rule” takes the stage. When a physician expects a patient’s stay to include at least two midnight stays, that person is an inpatient whose care is covered under Medicare Part A, which pays for hospitals. If it doesn’t last two midnights, Medicare expects the person to be an outpatient, and Part B, which pays for doctors, takes over. More expensive, though, are the fees at rehab places or nursing homes, which Medicare will pay for after three days of inpatient care. Those who’ve been outpatients don’t qualify for that benefit and can find themselves on the hook for five-figure sums. Meanwhile, administrators at the Johns Hopkins Hospita have taken to calling the policy the Cinderella Rule, said Amy Deutschendorf, senior director of clinical resource management: “If you cross two midnights, you’re an inpatient. If not, you’re a pumpkin.”Being a pumpkin can cost patients a lot of money. Under Part B, they’re billed separately for every procedure and visit and drug, and the co-pays can mount until patients owe hundreds or thousands of dollars — which they may only discover upon receiving the bills.So patients are complaining, and so are hospitals. Older people in emergency rooms often have complex problems, and they are strangers to the physicians who must decide whether to admit them or not. “Nobody looking at the patients who come through the door can predict who’s going to be here for two midnights,” Ms. Deutschendorf said. Yet a hospital that admits patients who don’t need two midnights’ worth of care may face Medicare audits, denied payments, fraud accusations and financial penalties.Legislation to allow any time spent in a hospital — as an inpatient or outpatient or both — to count toward the three-day requirement for skilled nursing coverage has gone nowhere in two Congresses, but it has acquired more than 100 House sponsors from both parties and more than 20 in the Senate. That may be the more likely situation, someday.Meanwhile, families should at least ask, when caregivers are attaching that little ID bracelet to your loved ones wrist if they are inpatient or outpatient.
In short, to receive full Medicare benefits for a hospital stay:
- The patient must be admitted. They can now stay for days for “observation,” and not actually be admitted. And they don’t have to inform you of the status. ASK! or wait until the bill comes. Pumpkin.
- They must be there over two midnights to receive the benefit. If they arrive two minutes after midnight, the whole first 24 hours don’t count toward the rule. Pumpkin.
- And if they don’t meet the two-midnights requirement then need follow-up rehab care: no coverage. Pumpkin.
Concerning this subject and any others relating to Medicare or its’ requirements, feel free to contact us at Rehab Home Health. We can certainly make sense of any questions you may have, and, as always, we’re available around the clock when your needs arise!
