Medicare Change of Status Notice Track Change version

VERSION FOR 60-DAY PUBLICATION
FINAL DRAFT

Style Definition: Normal
Style Definition: Heading 1: Font: (Default) +Headings
(Aptos Display), 20 pt, Not Bold, Font color: Accent 1, Left,
Space Before: 18 pt, After: 4 pt, Keep lines together
Style Definition: Heading 2: Font: (Default) +Headings
(Aptos Display), 16 pt, Not Bold, Font color: Accent 1, Space
Before: 8 pt, After: 4 pt, Keep lines together
Style Definition: Heading 3: Font: (Default) Times New
Roman, 14 pt, Font color: Accent 1, Left, Space Before: 8 pt,
After: 4 pt, Line spacing: single, Widow/Orphan control, Keep
lines together, Hyphenate, Tab stops: Not at -0.5"
Style Definition: Heading 4: Font: (Default) Times New
Roman, 12 pt, Italic, Font color: Accent 1, Space Before: 4 pt,
After: 2 pt, Line spacing: single, Widow/Orphan control, Keep
lines together

Patient name:
Patient number:
Hospital name:
Hospital address:

Medicare Change of Status Notice
Patient name:

Patient number:

Style Definition: Title: Font: (Default) +Headings (Aptos
Display), 28 pt, Not Bold, Condensed by 0.5 pt, Kern at 14 pt,
Indent: Left: 0", Space Before: 0 pt, After: 4 pt, Don't add
space between paragraphs of the same style, Widow/Orphan
control, Adjust space between Latin and Asian text, Adjust
space between Asian text and numbers
Style Definition: List Paragraph: Don't add space between
paragraphs of the same style
Style Definition: Style0
Style Definition: Body 2
Style Definition: Bullet 4: Indent: Left: 0.25", Hanging:
0.25"

Your hospital changed your status from inpatient to outpatient receiving observation
services. This means:
•

•

Your hospital bill might change depending on the Part B coinsurance you’ll owe as an
outpatient. If your Part B coinsurance is less than the Medicare inpatient hospital
deductible, you’ll get a lower bill. If your Part B coinsurance is higher than the inpatient
deductible, you’ll get a higher bill. Check with your hospital for more detailed billing
information.
You won’t have Medicare coverage in a skilled nursing facility (SNF) after you
leave the hospital.

Your Right to Appeal This Decision:
Important! You’re getting this notice because your hospital changed your status from “hospital
inpatient” to “hospital outpatient receiving observation services.”

The box marked below shows what applies to you:



Style Definition: Revision
Formatted: Font: 28 pt, Font color: Auto, Condensed by
0.15 pt, Kern at 14 pt
Formatted: Font: 28 pt, Font color: Auto, Condensed by
0.05 pt, Kern at 14 pt
Formatted: Font: 28 pt, Font color: Auto, Condensed by 0.1
pt, Kern at 14 pt
Formatted: Title, Space Before: 0 pt, Line spacing: single

Formatted: Condensed by 0.55 pt

While you’re still in the hospital, your hospital stay will now be billed to Medicare Part
B instead of Part A.
Your hospital bill may be lower or higher than the Part A inpatient deductible. Your
hospital can give you more information about billing.
After you leave the hospital, Medicare will not pay if you go to a skilled nursing
facility.

 While you’re still in the hospital, the hospital may charge you the full cost of your
outpatient hospital stay because you don’t have Medicare Part B.
After you leave the hospital, Medicare will not pay if you go to a skilled nursing
facility.
You Can Appeal
• You have the right to an immediate, independent medical review (can appeal) of the hospital’s
decision to change your status. Medicare authorized an independent your status change to a
Quality Improvement Organization (also known as a QIO) to perform this review. right away.
Quality Improvement Organizations are independent of Medicare.
• If you choosedecide to appeal, the QIOyour Quality Improvement Organization will ask for your
opinion. The QIO will also look at your medical records and/or other relevant information. You
don’t have to prepare anything in writing, but give you have the right to if you’d like. its decision
about 2 days after you ask for an appeal.
• If the QIO disagrees with your status change to an outpatient receiving observation
services, you may qualify for a Medicare-covered SNF stay after you leave the
hospital. You’ll be responsible for the Medicare inpatient hospital deductible.
• If the QIO agrees with your status change to an outpatient receiving observation
services, you won’t qualify for a Medicare-covered SNF stay after you leave the
hospital. You’ll be responsible for Medicare Part B copays.

Formatted: List Paragraph, Right: 0.36", Space Before: 8.2
pt, Bulleted + Level: 1 + Aligned at: 0.08" + Indent at:
0.27", No widow/orphan control, Don't adjust space between
Latin and Asian text, Don't adjust space between Asian text
and numbers, Tab stops: 0.27", Left + Not at 0.75" + 7.06"
Formatted: Condensed by 0.55 pt
Formatted: Condensed by 0.55 pt
Formatted: Condensed by 0.55 pt
Formatted: Condensed by 0.55 pt
Formatted: Condensed by 0.4 pt
Formatted: Condensed by 0.4 pt
Formatted: Condensed by 0.4 pt
Formatted: Condensed by 0.4 pt
Formatted: Condensed by 0.4 pt
Formatted: Condensed by 0.4 pt
Formatted: Condensed by 0.4 pt
Formatted: List Paragraph, Right: 0.18", Space Before: 2.15
pt, Bulleted + Level: 1 + Aligned at: 0.08" + Indent at:
0.27", No widow/orphan control, Don't adjust space between
Latin and Asian text, Don't adjust space between Asian text
and numbers, Tab stops: 0.27", Left + Not at 0.75"
Formatted: Condensed by 0.4 pt
Formatted: Condensed by 0.4 pt
Formatted: Condensed by 0.4 pt
Formatted: Condensed by 0.3 pt
Formatted: Condensed by 0.25 pt
Formatted

...

Formatted: Condensed by 0.25 pt
Formatted: Font: 10 pt
Formatted

...

Formatted: Condensed by 0.2 pt
Formatted: Condensed by 0.2 pt
Formatted: Condensed by 0.2 pt
Formatted: Condensed by 0.2 pt
Formatted: Condensed by 0.2 pt
Formatted: Condensed by 0.2 pt

How to Appeal your Status Change:
• Call your QIOQuality Improvement Organization to appeal at: {insert QIO name and toll-free number
of QIO}, or if you have questions.

Formatted: Condensed by 0.2 pt
Formatted: Condensed by 0.15 pt
Formatted: Condensed by 0.2 pt
Formatted: Condensed by 0.2 pt

• You should ask for an appeal as soon as possible and before you leave the hospital.
• The QIO will notify you of its decision as soon as possible, usually within 1 day of
getting all the necessary information.

Formatted: Condensed by 0.2 pt
Formatted: Condensed by 0.2 pt
Formatted: Condensed by 0.2 pt
Formatted: Condensed by 0.2 pt
Formatted: Condensed by 0.15 pt

• See pageAfter you leave the hospital, you still have appeal rights. Call your Quality Improvement
Organization.

Formatted: Condensed by 0.1 pt
Formatted: Font: Times New Roman
Formatted

...

What Happens After I Appeal?
• You’ll get the appeal decision from the Quality Improvement Organization about 2 of this
noticedays after you appeal, even if you leave the hospital.
• If you decide to stay in the hospital beyond your planned discharge date you may be
responsible for payment of services you get during the appeal process.
• If your appeal is favorable to you, Medicare may cover your skilled facility nursing stay after
you leave the hospital.

Formatted: Condensed by 0.45 pt
Formatted: Condensed by 0.45 pt

Questions?
• If you think you may want to appeal and want more information. about the appeals process,
call your Quality Improvement Organization at:

Formatted: Condensed by 0.3 pt
Formatted: List Paragraph, Right: 0.64", Space Before: 5.8
pt, Bulleted + Level: 1 + Aligned at: 0.08" + Indent at:
0.27", No widow/orphan control, Don't adjust space between
Latin and Asian text, Don't adjust space between Asian text
and numbers, Tab stops: 0.27", Left

• For more information about your Medicare coverage, call 1-800-MEDICARE (1800-633-4227). TTY users can call 1-877-486-2048.

Additional Information (Optional):

Formatted: Font: Gotham Bold
Formatted: Font: Gotham Bold, Condensed by 0.3 pt
Formatted: Font: Gotham Bold
Formatted: Font: Gotham Bold, Condensed by 0.25 pt
Formatted: Font: Gotham Bold, Condensed by 0.1 pt
Formatted: Font: Gotham Bold
Formatted: Heading 1

If You Miss the Deadline to Appeal, You May Have Other Appeal Rights:
• Call the QIO listed on Page 1.

Sign below to show you received and understood this notice.
Signature of patient or representative

Date

See page 2 of this notice for more information.

Form CMS 10868 No. 10868 • XX/XXXX • OMB approval 0938-XXXX

Formatted: Body Text, Space Before: 9.6 pt

You have the right to get Medicare information in an accessible format, like large print, braille, or audio. You also have the right to file a complaint

Formatted: Font: 8 pt
Formatted: Body Text, Space Before: 7.75 pt, Tab stops:
Not at 7" + 7.06"

if you feel you’ve been discriminated against. Visit

Medicare.gov/about-us/accessibility-nondiscrimination-notice,
or call 1-800-MEDICARE Visit Medicare.gov/about-us/accessibility-nondiscrimination-notice, or call 1-800-MEDICARE (1-800-

Formatted: Font: 8 pt, Condensed by 0.1 pt

633-4227) for more information. TTY users can call

Formatted: Font: 8 pt, Not Bold

(1-800-633-4227) for more information. TTY users can call 1-877-486-2048.

Formatted: Font: 8 pt, Not Bold, Condensed by 0.1 pt
Formatted: Font: 8 pt, Not Bold
Formatted: Normal, Indent: Left: 0.08", Space Before:
0.05 pt, Tab stops: Not at 7" + 7.06"

Additional Information (Optional):

Formatted: Font: Gotham Bold
Formatted: Font: Gotham Bold, Condensed by 0.3 pt
Formatted: Font: Gotham Bold
Formatted: Font: Gotham Bold, Condensed by 0.25 pt
Formatted: Font: Gotham Bold, Condensed by 0.1 pt
Formatted: Font: Gotham Bold
Formatted: Heading 1

Formatted: Body Text, Space Before: 9.6 pt

Please sign below to indicate you received and understood this notice.
I have been notified of my change in status from a hospital inpatient to a hospital
outpatient receiving observation services. I understand I may contact my QIO to appeal
this decision. I also understand if I win my appeal, my hospital charges will be different,
and possibly higher.

Signature of Patient or Representative

Date / Time

{Insert contact information here}Paid for by the Department of Health & Human Services.
Formatted: Font: 12 pt
Formatted: Normal, Space Before: 0 pt, Line spacing:
single

Form CMS 10868 (Exp. xx/xx/20xx)

OMB approval 0938-xxxx