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Can a Hospital Turn Away a Medicare Beneficiary Who Doesn't Have Medigap Insurance?

Q. I have power of attorney for my elderly mother, who has dementia. The nursing home where she lives says that she should have a medigap policy because some local hospitals may not admit her without one. Is this correct? At age 92, could she even obtain a medigap policy?

A. A hospital cannot insist that a Medicare beneficiary have supplemental insurance (also known as medigap) to be admitted. Such a practice could lead Medicare to terminate the hospital’s contract. The regulations say that the Centers for Medicare & Medicaid Services (CMS—the federal agency that runs Medicare) can terminate its contract with any provider that “places restrictions on the persons it will accept for treatment and fails either to exempt Medicare beneficiaries from those restrictions or to apply them to Medicare beneficiaries the same as to all other persons seeking care.”

Denying treatment to a Medicare beneficiary who doesn’t happen to have medigap insurance counts as unacceptable discrimination. This applies to any providers (including doctors’ offices and skilled nursing facilities) that accept Medicare patients.

(One caveat: These rules affect only beneficiaries enrolled in traditional Medicare. Those in aMedicare Advantage health planneed to go to hospitals, doctors and other providers that accept that particular plan to be sure that their treatment will be covered, except in a medical emergency. In any case, people enrolled in MA plans cannot have medigap insurance as well.)

It’s likely that the care facility where your mother lives was passing on faulty information. However, CMS says that any evidence of a hospital discriminating against beneficiaries without medigap insurance should be reported to Medicare through the help line at 1-800-633-4227.

Whether a 92-year-old suffering from dementia could obtain medigap insurance is doubtful. It may not be impossible. But federal protections for buying medigap on a guaranteed basis last only during a six-month window after the beneficiary has enrolled in Medicare Part B. Beyond this time limit­, which probably expired for your mother decades ago, a medigap insurer can refuse coverage or require higher premiums based on age, current health status and preexisting medical conditions.

Patricia Barry is a senior editor at the AARP Bulletin.

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