A federal appeals court has granted certain
hospital patients the right to appeal “observation stay” designations in a
ruling that many hope will lead to even greater access to Medicare-covered
long-term care services.
The law currently restricts eligibility for
Medicare-covered skilled nursing stays to patients who have held inpatient
status at a hospital for three nights. On Monday, Judge Michael P. Shea of the
U.S. District Court of Hartford, CT, ruled that as a matter of constitutional
due process, patients who are initially admitted as inpatients by a physician
but whose status is later changed to observation by their hospital have the
right to appeal to Medicare to be certified fully as hospital inpatients.
The reference case, Alexander v. Azar,
is a nationwide class action lawsuit filed by the Center for Medicare Advocacy
that went to trial in August 2019.
The rules previously have “forced many
Medicare beneficiaries to either pay thousands of dollars out of pocket for
that care or to forgo the needed care altogether,” the Centers for Medicare
Advocacy said in a release announcing the court’s decision. “While people with
Medicare can appeal virtually any issue affecting their coverage, the Centers
for Medicare & Medicaid Services has blocked attempts by
beneficiaries to appeal their hospital status.”
LeadingAge President and CEO Katie Smith Sloan
was unequivocal in her praise for the decision.
“We are very pleased with this ruling,” she
said in a statement to McKnight’s. “We believe that, ultimately,
the law needs to change so that the restrictions on Medicare eligibility because
of observation status should be repealed, however, and will continue advocating
for passage of legislation that counts all nights in the hospital toward the
required three-day stay.
“Ironically, CMS has lifted the three-day
requirement underlying this issue during the current crisis,” she added. “[We]
hope this means that the agency will support eliminating these restrictions
once the pandemic is lifted.”
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