When you are hospitalized, you have the right to get all the hospital care covered by Molina Dual Options that is necessary to diagnose and treat your illness or injury. The day you leave the hospital (your "discharge date") is based on when your stay in the hospital is no longer medically necessary. This section explains what to do if you believe that you are being discharged too soon.
Information you should receive during your hospital stay
When you are admitted to the hospital, someone at the hospital should give you a notice called important Message from Medicare about Your Rights. This notice explains:
- Your right to get all medically necessary hospital services covered.
- Your right to know about any decisions that the hospital, your doctor, or anyone else makes about your hospital stay and who will pay for it.
- That your doctor or the hospital may arrange for services you will need after you leave the hospital.
- Your right to appeal a discharge decision.
Review of your hospital discharge by the Quality Improvement Organization
If you think that you are being discharged too soon, ask your health plan to give you a notice called the Detailed Notice of Discharge & Molina Dual Options Appeal Rights. This notice will tell you:
- Why you are being discharged.
- The date that we will stop covering your hospital stay (stop paying our share of your hospital costs).
- What you can do if you think you are being discharged too soon.
- Who to contact for help.
- You (or someone you authorize) may be asked to sign and date this document, to show that you received the notice. Signing the notice does not mean that you agree that you are ready to leave the hospital - it only means that you received the notice. If you do not get the notice after you have said that you think you are being discharged too soon, be sure to ask for it immediately.
You have the right by law to ask for a review of your discharge date. As explained in the Detailed Notice of Discharge & Molina Dual Options Appeal Rights, if you act quickly, you can ask an outside agency called the Quality Improvement Organization to review whether your discharge is medically appropriate.
What is the "Quality Improvement Organization"?
"QIO" stands for Quality Improvement Organization. The QIO is a group of doctors and other health care experts paid by the federal government to check on and help improve the care given to Molina Dual Options patients. They are not part of our health plan or your hospital. There is one QIO in each state, KEPRO is the QIO for SC. The QIO doctors and other health experts review certain types of appeals and/or complaints made by Molina Dual Options patients. These include appeals and/or complaints about quality of care and appeals and/or complaints from Molina Dual Options patients who think the coverage for their hospital stay is ending too soon. You can refer to the Member Handbook for information on how to contact your state QIO.
1-844-455-8708 This call is free.
KEPRO team members are available 9:00 a.m. to 5:00 p.m. Monday
through Friday and from 11:00 a.m. to 3:00 p.m. on Saturdays,
Sundays, and holidays. You can also leave a message 24 hours a day,seven days a week.
Translation services are available for members and caregivers who do not speak English.
1-855-843-4776 This call is free.
This number is for people who have hearing or speaking problems. You must have special telephone equipment to call it.
5201 W. Kennedy Blvd., Suite 900
Tampa, FL 33609
Getting a QIO review of your hospital discharge
If you want to have your discharge reviewed, you must act quickly to contact the QIO. The Detailed Notice of Discharge & Molina Dual Options Appeal Rights, gives the name and telephone number of your QIO and tells you what you must do.
You must ask the QIO for a "fast review" of whether you are ready to leave the hospital. This "fast review" is also called a "fast appeal" because you are appealing the discharge date that has been set for you.
You must call the QIO before you leave the hospital and no later than your planned discharge date. This deadline is very important. If you meet this deadline, you are allowed to stay in the hospital past your discharge date without paying for it yourself, while you wait to get the decision from the QIO (see below).
If the QIO reviews your discharge, it will first look at your medical information. Then it will give an opinion about whether it is medically appropriate for you to be discharged on the date that has been set for you. By noon of the day after the reviewers tell us about your appeal, you will get a letter that gives your planned discharge date.
- If the QIO decides that your discharge date was medically appropriate, you will not be responsible for paying the hospital charges until noon of the calendar day after the QIO gives you its decision.
If the QIO agrees with you, then we will continue to cover your hospital stay for as long as medically necessary.
- What if you do not ask the QIO for a review by the deadline?
You still have another option: asking Molina Dual Options for a "fast appeal" of your discharge
- If you do not ask the QIO for a "fast review" ("fast appeal") of your discharge by the deadline, you can ask us for a "fast appeal" of your discharge. How to ask us for a fast appeal is covered briefly in the first part of this section and in more detail in the Member Handbook.
- If you ask us for a fast appeal of your discharge and you stay in the hospital past your discharge date, you run the risk of having to pay for the hospital care you receive past your discharge date. Whether you have to pay or not depends on the decision we make.
- If we decide, based on the fast appeal, that you need to stay in the hospital, we will continue to cover your hospital care for as long as medically necessary. If we decide that you should not have stayed in the hospital beyond your discharge date, then we will not cover any hospital care you received if you stayed in the hospital after the discharge date.
You may have to pay if you stay past your discharge date
- If you stay in the hospital after your discharge date and do not ask for immediate QIO review, you may be financially responsible for the cost of many of the services you receive. However, you can appeal any bills for hospital care you receive, by contacting Member Services.