Hospitals must maintain an accurate, up-to-date list of Medicare participating facilities and providers that can provide appropriate post-hospital care. Follow-up care can include placement in nursing homes, skilled nursing facilities, long-term acute care centers, and rehabilitation facilities. If you are returning home, you may get referrals for therapy services, home health care agencies, or hospice care. It is important to understand the coverage requirements for each type of post-hospital care to maximize your coverage and minimize out-of-pocket costs.
Regardless of whether you are being discharged to a facility or to your home, be sure to ask the hospital staff if you qualify for Medicare coverage of follow-up care. If you qualify for a discharge plan, the hospital must arrange transfers to skilled nursing facilities and provide referrals to home health and hospice agencies that accept your Medicare coverage. Hospital staff must also educate you, your family, and/or your caregivers about your care needs if you are returning home, and provide a clear list of instructions for your care, including all medications you will need.