Asking us to cover a longer hospital stay

When you are admitted to a hospital, you have the right to get all hospital services that we cover that are necessary to diagnose and treat your illness or injury. During your hospital stay, your doctor and the hospital staff will be working with you to prepare for the day when you will leave the hospital. They will also help arrange for any care you may need after you leave.

  • The day you leave the hospital is called your “discharge date.” Our plan’s coverage of your hospital stay ends on this date.
  • Your doctor or the hospital staff will tell you what your discharge date is.

If you think you are being asked to leave the hospital too soon, you can ask for a longer hospital stay. This section tells you how to ask.

Learning about your Medicare rights

Within two days after you are admitted to the hospital, a caseworker or nurse will give you a notice called An Important Message from Medicare about Your Rights. If you do not get this notice, ask any hospital employee for it. If you need help, please call Member Services (phone numbers are printed on the back cover of this booklet). You can also call 1-800-MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048), 24 hours a day, 7 days a week. Read this notice carefully and ask questions if you don’t understand. The Important Message tells you about your rights as a hospital patient, including:
Your right to get Medicare-covered services during and after your hospital stay. You have the right to know what these services are, who will pay for them, and where you can get them. Your right to be a part of any decisions about the length of your hospital stay. Your right to know where to report any concerns you have about the quality of your hospital care. Your right to appeal if you think you are being discharged from the hospital too soon. You should sign the Medicare notice to show that you got it and understand your rights. Signing the notice does not mean you agree to the discharge date told to you by your doctor or hospital staff. Keep your copy of the signed notice so you will have the information in it if you need it. To look at a copy of this notice in advance, you can call Member Services at 1-888-522-1298 (TTY: 711). You can also call 1-800 MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048), 24 hours a day, 7 days a week. You can also see the notice online. If you need help, please call Member Services at 1-888-522-1298 (TTY: 711). You can also call 1-800-MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048), 24 hours a day, 7 days a week.

Level 1 Appeal to change your hospital discharge date

If you want us to cover your inpatient hospital services for a longer time, you must request an appeal. A Beneficiary and Family-Centered Care Quality Improvement Organization will do the Level 1 Appeal review to see if your planned discharge date is medically appropriate for you.

To make an appeal to change your discharge date call the Livanta at: 1-877-588-1123 (TTY: 1-855-887-6668).

Call right away!

Call the Beneficiary and Family-Centered Care Quality Improvement Organization before you leave the hospital and no later than your planned discharge date. An Important Message from Medicare about Your Rights contains information on how to reach the Beneficiary and Family-Centered Care Quality Improvement Organization.

If you call before you leave, you are allowed to stay in the hospital after your planned discharge date without paying for it while you wait to get the decision on your appeal from the Beneficiary and Family-Centered Care Quality Improvement Organization.
If you do not call to appeal, and you decide to stay in the hospital after your planned discharge date, you may have to pay all of the costs for hospital care you get after your planned discharge date.
If you miss the deadline for contacting the Beneficiary and Family-Centered Care Quality Improvement Organization about
your appeal, you can make your appeal directly to our plan instead.

We want to make sure you understand what you need to do and what the deadlines are.

Ask for help if you need it. If you have questions or need help at any time, please call Member Services at 1-888-522-1298 (TTY: 711). You can also call the Health Insurance Counseling and Advocacy Program (HICAP) at 1-800-824-0780 or 1-213-383-4519 (TTY: 1-213-251-7920) or the Cal MediConnect Ombuds Program at 1-855-501-3077.

Ask for a “fast review”

You must ask the Beneficiary and Family-Centered Care Quality Improvement Organization for a “fast review” of your discharge. Asking for a “fast review” means you are asking for the organization to use the fast deadlines for an appeal instead of using the standard deadlines.

What happens during the review?

The reviewers at the Beneficiary and Family-Centered Care Quality Improvement Organization will ask you or your representative why you think coverage should continue after the planned discharge date. You don’t have to prepare anything in writing, but you may do so if you wish.
The reviewers will look at your medical record, talk with your doctor, and review all of the information related to your hospital stay. By noon of the day after the reviewers tell us about your appeal, you will get a letter that gives your planned discharge date. The letter explains the reasons why your doctor, the hospital, and we think it is right for you to be discharged on that date.

What if the answer is Yes?

If the review organization says Yes to your appeal, we must keep covering your hospital services for as long as they are medically necessary.

What if the answer is No?

If the review organization says No to your appeal, they are saying that your planned discharge date is medically appropriate. If this happens, our coverage for your inpatient hospital services will end at noon on the day after the Beneficiary and Family-Centered Care Quality Improvement Organization gives you its answer. If the review organization says No and you decide to stay in the hospital, then you may have to pay the full cost of hospital care you get after noon on the day after the Beneficiary and Family-Centered Care Quality Improvement Organization gives you its answer. If the Beneficiary and Family-Centered Care Quality Improvement Organization turns down your appeal, and you stay in the hospital after your planned discharge date, then you can make a Level 2 Appeal.

Level 2 Appeal to change your hospital discharge date

If the Beneficiary and Family-Centered Care Quality Improvement Organization has turned down your appeal, and you stay in the hospital after your planned discharge date, then you can make a Level 2 Appeal. You will need to contact the Beneficiary and Family-Centered Care Quality Improvement Organization again and ask for another review.

Ask for the Level 2 review within 60 calendar days after the day when the Beneficiary and Family-Centered Care Quality Improvement Organization said No to your Level 1 Appeal. You can ask for this review only if you stayed in the hospital after the date that your coverage for the care ended.
You can reach the Livanta at: 1-877-588-1123 (TTY: 1-855-887-6668).

Reviewers at the Beneficiary and Family-Centered Care Quality Improvement Organization will take another careful look at all of the information related to your appeal.

Within 14 calendar days, the Beneficiary and Family-Centered Care Quality Improvement OrganizationBeneficiary and Family-Centered Care Beneficiary and Family-Centered Care Quality Improvement Organization reviewers will make a decision.

What happens if the answer is Yes?

We must pay you back for our share of the costs of hospital care you have received since noon on the day after the date of your first appeal decision. We must continue providing coverage for your inpatient hospital care for as long as it is medically necessary. You must continue to pay your share of the costs and coverage limitations may apply.

What happens if the answer is No?

It means the Quality Review Organization agrees with the Level 1 decision and will not change it. The letter you get will tell you what you can do if you wish to continue with the appeal process. If the Quality Review Organization turns down your Level 2 Appeal, you may have to pay the full cost for your stay after your planned discharge date.

What happens if I miss an appeal deadline?

If you miss appeal deadlines, there is another way to make Level 1 and Level 2 Appeals, called Alternate Appeals. But the first two levels of appeal are different.

Level 1 Alternate Appeal to change your hospital discharge date

If you miss the deadline for contacting the Beneficiary and Family-Centered Care Quality Improvement Organization, you can make an appeal to us, asking for a “fast review.” A fast review is an appeal that uses the fast deadlines instead of the standard deadlines. During this review, we take a look at all of the information about your hospital stay. We check to see if the decision about when you should leave the hospital was fair and followed all the rules. We will use the fast deadlines rather than the standard deadlines for giving you the answer to this review. We will give you our decision within 72 hours after you ask for a “fast review.” If we say Yes to your fast review, it means we agree that you still need to be in the hospital after the discharge date. We will keep covering hospital services for as long as it is medically necessary. It also means that we agree to pay you back for our share of the costs of care you have received since the date when we said your coverage would end. If we say No to your fast review, we are saying that your planned discharge date was medically appropriate. Our coverage for your inpatient hospital services ends on the day we said coverage would end. If you stayed in the hospital after your planned discharge date, then you may have to pay the full cost of hospital care you got after the planned discharge date. To make sure we were following all the rules when we said No to your fast appeal, we will send your appeal to the “Independent Review Entity.” When we do this, it means that your case is automatically going to Level 2 of the appeals process.

Level 2 Alternate Appeal to change your hospital discharge date

We will send the information for your Level 2 Appeal to the Independent Review Entity within 24 hours of when we give you our Level 1 decision. If you think we are not meeting this deadline or other deadlines, you can make a complaint. Section 10 of this chapter tells how to make a complaint. During the Level 2 Appeal, the Independent Review Entity reviews the decision we made when we said No to your “fast review.” This organization decides whether the decision we made should be changed. The Independent Review Entity does a “fast review” of your appeal. The reviewers give you an answer within 72 hours. The Independent Review Entity is an independent organization that is hired by Medicare. This organization is not connected with our plan and it is not a government agency. Reviewers at the Independent Review Entity will take a careful look at all of the information related to your appeal of your hospital discharge. If the Independent Review Entity says Yes to your appeal, then we must pay you back for our share of the costs of hospital care you have received since the date of your planned discharge. We must also continue the plan’s coverage of your hospital services for as long as it is medically necessary. If this organization says No to your appeal, it means they agree with us that your planned hospital discharge date was medically appropriate. The letter you get from the Independent Review Entity will tell you what you can do if you wish to continue with the review process. It will give you the details about how to go on to a Level 3 Appeal, which is handled by a judge.

For Members Affected by the Wildfires

L.A. Care wants to ensure you have access to needed health services as our state deals with the current wildfire disaster. If you have been impacted by the wildfires, please note the following:

  • Prescriptions can be refilled at an out-of-network pharmacy if medications have been lost or left behind. Call 1-888-839-9909 for further assistance.
     
  • Clinical Services can be accessed out-of-network if your usual provider is unable to work due to the wildfires. Call 1-888-522-1298 for guidance in this situation.

Medical transportation, mental health services and additional information is available at the L.A. Care website.

 

H8258_15129_2015CMC
CMS Approved
Updated 06/14/2016

 

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