Questions for the discharge planner

Before anything else

• What is your name and direct number? Who covers when you are off?
• Is this stay inpatient or observation? (It changes what Medicare pays for afterward.)
• What is the expected discharge date, and how much notice will we get?

Where next

• What level of care do you think they need next, and why?
• Could they go home with home health, or do they need short-term rehab first?
• If rehab: which facilities have accepted, and can we choose among them?
• If a longer-term move: what paperwork is needed, and are the PRI and SCREEN done if a nursing home is possible?

Who pays

Under Original Medicare, a skilled nursing stay for rehab is generally covered only after a qualifying inpatient hospital stay, and only for a limited number of days, with a daily copay after the first twenty. Medicare Advantage plans can have different rules and often need approval first. Ask:

• What will Medicare or the plan cover, and for how long?
• What happens when coverage ends? What will it cost then?
• Does anything need prior approval from the insurance plan?

Going home

• Which services are ordered: home health nursing, therapy, an aide? Which agency, and when is the first visit?
• What equipment is coming, and when?
• Which medicines are new, changed, or stopped?
• Which follow-up appointments are booked?
• Which warning signs mean call the doctor, and which mean 911?

If it feels too soon

Medicare patients get a written notice about discharge rights and can ask for a fast appeal; the number to call is on the notice. You can ask for a family meeting and for the plan in writing.