Questions to Ask the Hospital Case Manager in New Jersey
The Discharge Meeting Is Not a Formality
When the hospital case manager sits down with you to discuss your parent's discharge, they are not asking for your opinion on whether it should happen. They are telling you it is happening and presenting the logistics. Your job in that meeting is to ask the questions that expose gaps in the plan before your parent leaves the building.
New Jersey hospitals must begin discharge planning within 24 hours of admission under N.J.A.C. 8:43G-11.5. Under the CARE Act (N.J.S.A. 26:2H-5.28), the designated caregiver is entitled to consultation and training at least 24 hours before discharge. These are your legal hooks for slowing down a process that can otherwise move faster than you are ready for.
Admission Status Questions
Ask these first. The answers determine everything downstream.
"Is my parent classified as inpatient or observation?" This is the single most important question. Observation status means Medicare Part A will not cover skilled nursing facility rehab afterward. If the answer is observation, ask why, and ask whether a physician review of the classification has been done.
"Has a Medicare Change of Status Notice been issued?" If the hospital reclassified your parent from inpatient to observation, they are required to deliver a written MCSN. You have the right to appeal the reclassification through Commence Health.
"How many qualifying inpatient midnights has my parent accumulated?" Medicare requires three consecutive inpatient midnights for SNF coverage. Know the count.
Post-Discharge Care Questions
"What skilled services does my parent need after discharge?" Get specifics: physical therapy, occupational therapy, wound care, medication management. Not "they'll need some help at home."
"Has a certified home health agency been contacted and confirmed?" Not recommended — confirmed. Has the agency accepted the referral, and when is the first visit scheduled?
"What durable medical equipment needs to be in the home before discharge?" Hospital beds, walkers, shower chairs, grab bars, oxygen. Ask whether the equipment has been ordered, when it will be delivered, and whether Medicare or the MCO is covering it.
"Has my parent's medication list been reconciled?" Medication errors during care transitions are among the leading causes of hospital readmission. Every new prescription should be cross-referenced against pre-admission medications to flag interactions, duplications, and discontinued drugs. Ask for a printed, reconciled medication list.
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Facility Transfer Questions
If the case manager is recommending an SNF or subacute rehab facility:
"Does this facility accept my parent's insurance — specifically, are they in my parent's MCO network?" If your parent is enrolled in an NJ FamilyCare MCO (Horizon NJ Health, Aetna Better Health, UnitedHealthcare Community Plan), the facility must be in-network. Ask the case manager to confirm, not assume.
"Has the EARC screening been completed?" For a patient expected to transfer to an SNF when Medicaid may pay for some or all of the stay, ask whether they are eligible for EARC: the screening is for patients who are Medicaid-eligible but not yet enrolled in an MCO, or who are expected to spend down and become eligible within 180 days. It provides a 90-day clinical authorization and is valid for only 10 days — if the transfer does not happen within that window, a new screening is required.
"Has a PASRR Level I screening been completed?" Every patient entering a Medicaid-certified SNF must undergo a Preadmission Screening and Resident Review regardless of payment source. If the screen is positive for mental illness or developmental disability, a Level II evaluation is required before admission.
"What is this facility's policy when Medicare coverage ends?" Some SNFs require a commitment to private pay or a pending Medicaid application before they will accept a patient they expect to transition to long-term care. Know the conversion policy before your parent arrives.
CARE Act Enforcement Questions
"Has the caregiver training required under the CARE Act been scheduled?" The hospital must provide live or recorded demonstrations of every medical after-care task your parent needs at home. If you need to manage wound changes, administer injections, or operate medical equipment, the clinical team must train you and document the training.
"Can I get the discharge plan in writing — including the hospital contact number?" New Jersey regulations require written discharge instructions with a direct phone number for a hospital contact person. That phone number is your lifeline for the first 48 hours after discharge.
The Question Most People Forget to Ask
"What should I do if something goes wrong in the first 72 hours?" You want specific answers: which symptoms warrant an ER return, which warrant a call to the primary care physician, and which can wait for the first follow-up appointment. The case manager should walk through clinical red flags in plain language.
The Hospital-to-Home in New Jersey guide includes a printable question checklist for the discharge meeting, a medication reconciliation tracker, and scripts for requesting CARE Act compliance.
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